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Refer a Patient

MRI Referral Form

CT Referral Form

X-Ray Referral Form

24Hour/14 Day Loop

Treadmill Referral

BP Referral Form

Echo Referral Form

ECG Referral Form

Ultrasound Referral

CT Colonography Referral

Please fill in the form below to refer your patient for treatments other than those above.

What happens after a referral has been submitted?

Your referral will be triaged by a consultant radiologist or one of our radiographers. We aim to place your patient with an appropriate specialist within 5 working days..

Once your referral has been accepted our booking team will be in touch to discuss appointment times.

To ensure this process is as seamless as possible, please check your referral has

Your details (Name, address, and DOB)
Clinical information
Signature and date from referrer
Clearly referring for a scan - not for assessment by a specialist i.e knee consultant

If you have any queries in relation to your referral status or your booking, please submit a request to Imaging Request. Thank you for your referral.

Referring Clinician Details

Doctor Name * Practice Address * Contact Number * Email *

Patient Details

Patient Name * Patient Address * Date of Birth *

Contact Number * Patient Email *

Referral Details

Specialiality * Consultant * Reason for referral * Funding *

Insured

Self-funding

Funding referral *

If the named consultant is unable to see your patient within our target of 7 working days, would you be happy for us to refer to another appropriate consultant?

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Help & Support

Kingsbridge Help & Support

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