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We are delighted to be able to offer patients the chance to self refer for an MRI scan, therefore a referral from your GP is not necessary.

Fill out the form below to request an MRI scan at One Ashford Hospital

Treatment	Guide Price
Self-Refer MRI from	£570

If you have any questions, please contact the Imaging Team on 01233 423269

Contact Regarding Referral*
- In order for us to process your enquiry please confirm that we can contact you regarding your referral
Agree to Privacy and Terms*
- I have read and agree to the privacy policy and terms and conditions
Your Personal Details
Title*
Mr, Mrs, Miss, Ms, etc.
First Name*
Last Name*
Date of Birth*
Gender*
Do you play paid professional sports?*
Address Line 1*
Address Line 2
Town / City*
County*
Postcode*
Telephone*
Email*
Referal
Are you*
- Referring Yourself
- Being Referred
Self Referral
Please provide details of your NHS doctor for forwarding results of your investigation.
Sharing Consent*
- I hereby consent to you sharing my information with my GP
NHS Practice name*
NHS GP name*
NHS Practice Telephone
NHS Practice Email
Address Line 1*
Address Line 2
Town / City*
County*
Postcode
Referred
Please provide details of your referring clinician for forwarding results of your investigation.
Sharing Consent*
- I hereby consent to you sharing my information with my referring clinician.
Name*
Referring Clinician*
Telephone
Email
Address Line 1*
Address Line 2
Town / City*
County*
Postcode
Examination
Select the examination required*
MRI Scan - Safety Information
Do you have or have you ever had a cardiac pacemaker or internal defibrillator fitted to your heart?*
Have you ever had any operations or procedures carried out on your head, heart, eyes or ears?*
Have you had any operations or procedures carried out on any blood vessels in your body, such as aneurysm or vascular clips?*
Do you have any implants in, or medical devices attached to your body?*
Have you ever had a penetrating injury to your eyes involving metal?*
Have you ever suffered a shrapnel injury (bomb blast or gunshot)?*
Have you had any surgery or procedures carried out in the past 6 weeks?*
Do you have a history of cancer or a long term medical condition related to the area to be scanned?*
Are you pregnant?*
The Examination
Please provide as much information as you can as to why you would like this scan.
Why do you want this scan?*
What symptoms are you experiencing?*
How long have you had symptoms?*
Select Body Area 1*
Select Body Area 2
(if required)
Select Body Area 3
(if required)
Once you submit the form we will contact you to discuss your scan, arrange an appointment and make payment.

Your Personal Details

Referal

Self Referral

Please provide details of your NHS doctor for forwarding results of your investigation.

Referred

Please provide details of your referring clinician for forwarding results of your investigation.

Examination

MRI Scan - Safety Information

The Examination

Ways To Pay

Use Your Insurance

Pay For Yourself

Spread The Cost

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