Book an Appointment Self Referral HomeBook an Appointment Self Referral Book an Appointment ( Self Referral) Select Service Type * Service TypeMRIUltrasound Enter Your Full Name * Enter Your Body Parts * (0) —Please choose an option—MRI Whole BodyMRI HeadMRI CardiacMRI Spine lumbar and sacralMRI Spine thoracicMRI Spine cervicalMRI Knee LtMRI Knee LtMR AngiographyMRA Carotid BothMRI AbdomenMRI Acetabulum LeftMRI Acetabulum RightMRI Achilles tendon LeftMRI Achilles tendon RightMRI Acromioclavicular joint LtMRI Acromioclavicular joint RtMRI Ankle LtMRI Ankle RtMRI Arthrogram ankle LtMRI Arthrogram ankle RtMRI Arthrogram elbow RtMRI Arthrogram hip RtMRI Arthrogram knee LtMRI Arthrogram knee RtMRI Arthrogram shoulder LtMRI Arthrogram shoulder RtMRI Arthrogram wrist LtMRI Arthrogram wrist RtMRI Axilla LtMRI Axilla RtMRI Brachial plexusMRI Breast BothMRI Calcaneus LtMRI Calcaneus LtMRI Clavicle RtMRI CraniofacialMRI Elbow LtMRI Elbow RtMRI Femur LtMRI Femur RtMRI Fingers LtMRI Fingers RtMRI Foot LtMRI Foot RtMRI Forearm LtMRI Forearm RtMRI Forefoot RtMRI Groin LeftMRI Groin RightMRI Hand LtMRI Hand RtMRI Hindfoot LtMRI Hindfoot RtMRI Hip LtMRI Hip RtMRI IAMMRI LiverMRI Lower leg LtMRI Lower leg RtMRI MandibleMRI Midfoot LtMRI Midfoot RtMRI Orbit BothMRI PancreasMRI ParotidMRI PelvisMRI Pelvis gynaecologicalMRI Pelvis rectumMRI Pelvis SIJMRI Perianal FistulaMRI PerineumMRI PituitaryMRI Prostate ScreeningMRI Salivary glandsMRI Scaphoid LeftMRI Scaphoid RightMRI Scapula LtMRI Scapula RtMRI SinusesMRI Skull baseMRI Small bowel studyMRI Soft Tissue NeckMRI Spinal cordMRI Spine CoccyxMRI SternumMRI Temporal lobeMRI Temporomandibular joint BothMRI ThoraxMRI Thumb LtMRI Thumb RtMRI ThyroidMRI Trigeminal nerveMRI Upper arm LtMRI Upper arm RtMRI Urinary BladderMRI Wrist LtMRI Wrist Rt Enter Your Body Parts * —Please choose an option—US AbdomenUS Abdominal aortaUS Ankle LtUS Ankle RtUS Anterior Abdominal WallUS Biceps tendon LtUS Biceps tendon RtUS Calf LtUS Calf RtUS Elbow LtUS Elbow RtUS Foot LtUS Foot RtUS Forearm LtUS Forearm RtUS Groin LtUS Groin RtUS Hand LtUS Hand RtUS Hip LtUS Hip RtUS Knee LtUS Knee RtUS Lumps and Bumps (One area)US Lumps and Bumps (Two areas)US NeckUS PelvisUS Pelvis TransabdominalUS Pelvis, Transabdominal and Transvaginal (Female)US Renal tractUS Shoulder LtUS Shoulder RtUS TestesUS Thigh LtUS Thigh RtUS ThyroidUS Upper Arm LtUS Upper Arm RtUS Upper Arm RtUS Urinary tractUS Wrist LtUS Wrist Rt Select Your Location * —Please choose an option—LeicesterLondon Next Do you have a referral? * Choose to refer yourself (18+) or upload your clinical referral letter. I am Refering My SelfI Have Refferal BackNext Prefix Mr.Mr.Mrs.Ms.Mr.Dr.Prof. Patient First Name * Patient Last Name * Patient Phone * Patient Email * Patient Post Code * Patient Date of Birth Gender GenderMaleFemale To process your enquiry, please confirm that we can contact you regarding your referral and that you agree to the Privacy Policy and Terms & Conditions. I agree* I would like to receive occasional offers and updates from Eastgate Health with the option to opt out at any time. I agree to receiving marketing information from Eastgate Health Prefix Mr.Mr.Mrs.Ms.Mx.Dr.Prof. Patient First Name * Patient Last Name * Patient Phone * Patient Email * Patient Post Code * Patient Date of Birth Gender GenderMaleFemale To process your enquiry, please confirm that we can contact you regarding your referral and that you agree to the Privacy Policy and Terms & Conditions. I agree* I would like to receive occasional offers and updates from Eastgate Health with the option to opt out at any time. I agree to receiving marketing information from Eastgate Health BackNext Why do you want this examination? What symptoms are you experiencing? How long have you had symptoms for? Why do you want this examination? What symptoms are you experiencing? How long have you had symptoms for? BackNext Do you have, or have you ever had, a cardiac pacemaker or internal defibrillator fitted to your heart? —Please choose an option—Select an option...NoYes Have you ever had any operations or procedures carried out on your head, heart, eyes or ears? —Please choose an option—Select an option...NoYes Have you ever had a penetrating injury to your eyes involving metal? —Please choose an option—Select an option...NoYes Have you ever suffered a shrapnel injury (bomb blast or gunshot)? —Please choose an option—Select an option...NoYes Have you had any surgery or procedures carried out in the past 6 weeks? —Please choose an option—Select an option...NoYes Do you have a history of cancer or a long term medical condition related to the area to be scanned? —Please choose an option—Select an option...NoYes Do you play paid professional sports? —Please choose an option—Select an option...NoYes Is there any chance you could be pregnant? —Please choose an option—Select an option...NoYes Have you had any operations or procedures carried out on any blood vessels in your body, such as aneurysm or vascular clips? —Please choose an option—Select an option...NoYes Do you have, or have you ever had, a cardiac pacemaker or internal defibrillator fitted to your heart? —Please choose an option—Select an option...NoYes Have you ever had any operations or procedures carried out on your head, heart, eyes or ears? —Please choose an option—Select an option...NoYes Have you ever had a penetrating injury to your eyes involving metal? —Please choose an option—Select an option...NoYes Have you ever suffered a shrapnel injury (bomb blast or gunshot)? —Please choose an option—Select an option...NoYes Have you had any surgery or procedures carried out in the past 6 weeks? —Please choose an option—Select an option...NoYes Do you have a history of cancer or a long term medical condition related to the area to be scanned? —Please choose an option—Select an option...NoYes Do you play paid professional sports? —Please choose an option—Select an option...NoYes Is there any chance you could be pregnant? —Please choose an option—Select an option...NoYes Have you had any operations or procedures carried out on any blood vessels in your body, such as aneurysm or vascular clips? —Please choose an option—Select an option...NoYes No file chosen Drag & drop your letter here Drop files here or click to upload. Upload up to 2 files Can’t find your referral letter? I can’t find my referral letter, please contact me. BackNext I hereby consent to you sharing my information with my GP I agree I Agree NHS Practice Name NHS GP Name (Optional) Address Line 1 Address Line 2 Town/City Postcode Submit Appointment Back
