Scan Request Form

Scan required (Please specify if contrast needed)

Clinical Details

(Brief History and Provisional Diagnosis)

MRI Contraindications

Other Information

Does the patient require any additional assistance:

Hearing Mobility Speech Other

Interpreter Required (If so, which Language)

Is the Patient Pregnant YesNo

Billing Information:

Type of Scan required

ContastYesNo

Number of parts:

Referring clinician’s name and GMC number

Abdominal bloating/fullness in the abdomen

Altered bowel habits

Anal abscess

Anal fissure

Anal fistula (pus and blood discharge)

Anal or rectal bleeding

Anal pain and infection

Angina

Arrhythmias

Atrial fibrillation

Belching

Blackouts

Breathlessness

Chest pain

Chest pain or discomfort

Chronic abdominal pain/ abdominal discomfort

Coronary Artery Disease

Diarrhea

Difficulty in swallowing

Dizzy spells

Ear discharge

Ear pain

Faecal incontinence or soiling

Groin pain

Haemorrhoids(piles)

Headaches and migraines

Hearing loss

Heart Attack

Heart burn

Heart rhythm problems (arrhythmias)

High blood sugar

High cholesterol

High or low blood pressure

Hypoglycemia (low blood glucose)

Indigestion and Acid reflux

Irregular heartbeat

Ischaemic heart disease

Leg swelling

Lumps and bumps in the body

Nausea

Oedema

Palpitations

Peri anal itching

Perianal discharge ( mucus or pus)

Pilonidal sinus disease

Presence of lumps in and around anus

Racing heartbeat (tachycardia)

Rectal bleeding( blood in the stools)

Scaly or rough skin

Slow heartbeat (bradycardia)

Swellings/ Hernia in the groin and abdominal wall

Syncope

Ulcers

Upper abdominal ( stomach )/colicky abdominal pain

Vomiting

Scan Request Form

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