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Riverside Clinic Brentford
Services
Diagnostic tests
Mens Health and Prostate Screening
Private GP services
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Consultant Clinics
Contact
Contact Riverside Clinic
Location
Radiology Referral
0330 127 3229
info@riverside-clinic.org.uk
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Radiology
Referrals
Radiology referral form to be completed by a GP or clinician. If you would like to self-refer, please contact us directly.
In order to refer a client to Healthshare, we first require information from you. Please fill in the form below in its entirety.
Alternatively, you can download the form and to by email to
info@riverside-clinic.org.uk
.
Click here to download
.
Diagnostic
services
Diagnostic tests
MRI
Digital X-Ray
Ultrasound
Echocardiology
Blood tests
Endoscopy
Referral
form
Surname
Forename
Gender
Male
Female
Date of Birth
Contact Numbers
Work:
Home:
Mobile:
Address
Examination Required
Clinical Information
Insurance Provider (if applicable)
Policy Number
Auth Code
Referring Clinician
Clinician Code
MRI Patients ONLY - These questions MUST be completed
Has the patient any of the following?
Cardiac Pacemaker
Internal hearing device
Aneurysm clips
Metal implants/clips
Risk of metallic intraocular foreign body
* These are absolute contradiction to MRI
Possibility of pregnancy?
Yes
No
Patient's weight
kg
LMP Date:
I confirm I am a medically trained doctor or registered health professional.
Consent to use and store your information.
Yes
No
Validation
Submit