Referrals

Patient details

Patient Name

Date of Birth

Telephone

Address

Postcode

Investigation required

Clinical details

Safety information

Last menstrual period (LMP)

MRI safety

cardiac pacemaker
Metallic foreign body

Please provide details of cardiac pacemaker if MRI compatible

Please provide details of metallic foreign body

Appointment

The first available appointment will be made to see one of the BMSR Consultants. However, if there is a specific BMSR Consultant the patient wishes to see then please enter their name below.

Payment

Payment option

Insurance
Self pay

Insurance provider

Policy number

Referrer details

Name of referring clinician

Address of referring clinician

BMSR Data Policy

1) The information collected from this referral form will only be used to ensure that an appointment is made for you with one of our private hospitals. 2) The information will be passed to your choice of private hospital and once the information is no longer required it will be removed from this secure website. 3) Information will never be held longer than required and never passed or used inappropriately. View our full privacy policy here.

Data protection*

I am happy for BMSR to handle this clinical information and pass the information on to the private hospital to book an appointment.

Authorisation*

I confirm the details are correct and 'virtually' signed by a medical professional.

Email

This field is for validation purposes and should be left unchanged.

Referral form