E-Referral MRI

E-Referral GP MRI Form

Patient Details

Gender *
(Auto calculated from DOB)
Booking Appointment


MRI Knee
MRI Head
MRI Spine
MRI Under 16 - Hip, Elbow, Wrist
MRI side

Clinical History

Is or may the patient be pregnant?
Contrast Allergy
Diabetes Metformin
Renal Disease

MRI Checklist

Pacemaker / Heart Valves
Aneurysm Clips
Cochlear / Ear Implants
Metallic foreign body to eye
Other metallic/electronic devices

Referring Practitioner

(Used to login to InteleViewer or Inteleconnect)
Copies to another referrer?
Please select most appropriate branch but the appointment may be at another branch.
Branch *