Self-referral Scans

We are delighted to be able to offer patients over the age of 18 the chance to self refer for MRI and ultrasound diagnostic scan, making the need for a referral from your GP not necessary.

Fill out the form below to request an MRI or ultrasound scan at One Hatfield Hospital

For us to process your enquiry please confirm that we can contact you regarding your referral

GP Triage Fee*
- I am aware of the £50 non-refundable GP triage fee
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 heart?*
Please specify*
Have you EVER had any metal fragments in your eyes?*
Please specify*
Do you have any of the following: aneurysm clip, programmable hydrocephalus shunt or cochlear implant?*
Please specify*
Have you had any operations on your head or spine?*
Please specify*
Have you had any surgery or procedures carried out in the past 6 weeks, including gastro intestinal investigation?*
Please specify*
Have you ever suffered a shrapnel injury (bomb blast or gunshot)?*
Please specify*
Have you had any tattoos in the last 6 weeks?*
Have you ever had any operations or procedures carried out on your ears?*
Please specify*
Have you had any operations that involved metal clips, pins, plates or implants?*
Please specify*
Do you suffer from epilepsy or have you ever had a fit/blackout?*
Please specify*
Do you wear a medicine patch? (Nicotine, contraception, angina patch or flash glucose monitoring system)?*
Please specify*
Do you have any hair extensions, piercings or derma piercing?*
Please specify*
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)
*The hospital will not take responsibility for the request for an incorrect scan or body area. If you are unsure of the scan service needed, please contact a member of our reservations team to make an appointment with a GP.

Once you submit the form we will contact you to discuss your scan and collect payment.

Please note that without GP triage fee we cannot process your request.
Phone
This field is for validation purposes and should be left unchanged.

Please note that all results will be returned to a clinician and not directly to the patient

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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