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Request a Scan

If you are a member of the public and would like to request a scan, please fill in the details below.

Ultrasound scans are performed at our clinic in St Albans and can be used for Sexing Scans, Nuchal Scans and Viability Scans.

Scan Details
Type Of Scan: Ultrasound    Xray    CT Scan    MRI    Nuclear Medicine
Examination Required:
Reason for scan:

Patient Details
Name:
Date of Birth:   (dd/mm/yyyy)
Address:
Post Code:
Telephone (include std code):
Mobile/Daytime:
Email:
Sex: Male  Female
Age:


Medical Details

 
Name of doctor:
Surgery Address:
Name of consultant to be seen by:  
Referral letter? Yes   No
Requested date of appointment:  (dd/mm/yyyy)
Funding? Self Funding   Insured 
Clinical/Medical History:

 
Additional Comments:
Person completing form? Patient GP     (If GP, please enter GMC Number: )
Send films to? Patient Referrer

Optionally, you can print this form & post it or fax it to us on:  01727 898164

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