IRIS - Self Referral

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Self Referral (*) marked are mandatory

Please select your MRI Scan Location *

Please select body part(s) to be scanned *

First Name *

Last Name *

Title

Address *

Town *

Postcode *

Gender*

Date Of Birth *

Enter Mobile Number*

Enter Telephone

Enter Email

Patient Clinical Information(Presenting complaint & reason for an MRI scan?):

Previous surgery Details:

Previous Imaging Details:

Questionnaire

Do you have a cardiac pacemaker or intra-cardiac device? Yes No

Have you ever had surgery to your brain, heart, eyes, or ears? Yes No

Have you had any surgery in the last 6 weeks? Yes No

Do you have any aneurysm clips, surgical implants, internal devices, stents or shunts? Yes No

Have you ever, in your lifetime, had an accident where metal may have entered your eyes or your skin? Yes No

Do you wear a medicated skin patch or monitoring device? Yes No

Are you or might you be pregnant? Yes No

Do you weigh more than 21 stones / 133kg? Yes No

Protocol Status

Protocolled On

Protocoller

Protocol Comments

NHS/Unique Identification Number

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