Please sign the document in order to complete the referral process. Without a signature the document will not be processed by the referral team.

UME Health

Imaging Referral Form

Telephone: 0207 467 6190
17 Harley Street, London W1G 9QH
Patient details (affix label if available)
Title: Address:
Firstname: Surname:
Dob: Gender:
Postcode: Phone number:
Funding type: Insurance company:
Email Address: Policy number:
Mobility: Authorisation code:
Body part: Clinical indication:
Diagnostic Tests
Diagnostic Tests:  
Contrast investigations
For patients above 65 years of age or with any known problems with kidney function, serum creatinine level or eGFR must be available prior to imaging.
Serum creatinine/eGFR reading: Date Taken:

Safety check as recommended by the MHRA, the referring clinician is required to assess patient safety for MRI scans.
Cardiac pacemakers, artificial heart valves, cochlear implants, cerebral aneurysm clips are contra-indicated for MRI.
Does the patient have a metal implant or pacemaker?
Has the patient ever had an injury to the eye involving a metallic object?
Referring clinician’s details
Referrer name: Date:
GMC number: Contact Telephone Number:
Email Address: Preferred Radiologist:
Please indicate how you would like to receive
the results of the investigation?:
Encrypted Email: Postal Address:
Do you wish to receive a CD copy of images?:  

Leave this empty:

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Signature Certificate
Document name: Imaging Referral Form
lock iconUnique Document ID: 7355f26a7fbf79e0eea500008d2e286102c4e61e
Timestamp Audit
September 13, 2021 9:35 am BSTImaging Referral Form Uploaded by Shimaa Ahmed - IP