All fields marked with * are required. Please contact Egress Support via support@egress.com if you have any issues with completing the form. Please do not share personal / medical information with Egress Support, this is for technical support only, relating to completion of the online referral form.

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Referring a patient

Please ensure you detail the patient’s medical history and any other relevant information pertaining to this referral.

The patient must:

• Be registered with a GP

• Be 18 years of age or older

• Not present with any red flag indications

• Not be a medical emergency

How is the examination being funded?(Required)

Examination Information

The Ionising Radiation (Medical Exposure) Regulations (IRMER) 2017 and MHRA MRI Safety guidelines require you to complete all the following information.

Which Modality is required?(Required)

Please indicate if any of the following conditions apply to your patients.

Cardiac Pacemaker or ICD(Required)

Unfortunately, we are unable to accept your referral for an MRI at Ramsay Hospitals. Please refer the patient to your local NHS Trust for MRI Imaging.

Aneurysm Clip(Required)

Unfortunately, we are unable to accept your referral for an MRI at Ramsay Hospitals. Please refer the patient to your local NHS Trust for MRI Imaging.

Hydrocephalus Shunt(Required)

Unfortunately, we are unable to accept your referral for an MRI at Ramsay Hospitals. Please refer the patient to your local NHS Trust for MRI Imaging.

Cochlear Implant(Required)

Unfortunately, we are unable to accept your referral for an MRI at Ramsay Hospitals. Please refer the patient to your local NHS Trust for MRI Imaging.

Implantable Drug Infusion pump(Required)

Unfortunately, we are unable to accept your referral for an MRI at Ramsay Hospitals. Please refer the patient to your local NHS Trust for MRI Imaging.

Neurostimulator(Required)

Unfortunately, we are unable to accept your referral for an MRI at Ramsay Hospitals. Please refer the patient to your local NHS Trust for MRI Imaging.

Metallic Foreign Body in the eye(s)(Required)
Recent endoscopy involving a “PillCam”(Required)
Any Renal impairment?(Required)

Patient Details

It is essential that we have up to date contact information for your patient in order to provide accurate and timely details about appointments and treatment with us.

GP Details

Auto-populate Referrer Details
Does the patient have any additional needs?(Required)
Please confirm additional needs
Does the patient have capacity to consent?(Required)
Is there a possibility the patient may be pregnant?(Required)

Referrer Information

Referrer’s Declaration

THIS IS A LEGAL DOCUMENT

  • The correct patient details have been entered.
  • I have discussed this examination with the patient/guardian.
  • I have taken into account the possibility of pregnancy.
  • I have given sufficient clinical information for the request to be justified according to IR(ME)R 2017.
  • I will ensure that the examination result is recorded in the patient’s case notes.

By clicking confirm I certify that I am authorised (as a registered healthcare professional) to request imaging examinations and this is an electronic representation of my signature.