Follow the steps to complete the MRI Referral Form online.

1. Press the 'Get Form' button to access and open the MRI Referral Form in your preferred editor.
2. Begin by filling in the patient details. Include the patient's first name, surname, and date of birth. Indicate their preferred title from the options provided: Mr, Mrs, Miss, Dr, or Other. Specify if the patient identifies as male or female.
3. Input the patient's contact information, including their mobile number, home telephone number, and email address. Ensure the address and postcode are complete for proper correspondence.
4. Identify the payment method by indicating whether the patient will be self-paying or using insurance. Enter the insurer's name and policy number, if applicable.
5. Provide relevant clinical details and specify the regions to be scanned. Indicate any additional requirements, such as a 3T MRI or gadolinium usage.
6. Answer the safety check questions regarding the patient's medical history, including any cardiac devices, previous surgeries, and potential contraindications for undergoing an MRI scan.
7. Complete the referring clinician's details. Include your title, name, specialty or profession, and indicate how you prefer to receive the report by circling one of the options: by email, by post, or by fax.
8. If applicable, provide details for another clinician to receive the report, including the hospital or practice name, address, postcode, email, and telephone number.
9. After reviewing the entire form, ensure that all required fields are filled out and accurate. Finally, sign and date the form to confirm your understanding of MRI contraindications and potential implications.
10. Once completed, submit the form as indicated, either by emailing it to help@vistadiagnostics.co.uk or faxing it to 0845 4502171. You may also save changes, download a copy, or print the form for your records.

Complete your MRI Referral Form online today for a seamless patient referral process.