Warning!

If your patient has any of these conditions he/she may not be suitable for MRI scanning.

blue bullet Cardiac Pacemaker 

blue bullet Intra-cranial clips

blue bullet Implants (e.g. cochlear, neuro stimulators)

blue bullet Intra-orbital metallic fragments 

blue bullet Pregnancy

Please contact NorthernMRI for advice on 028 9066 0050

If you would like to make an appointment for a patient please complete this online form and Northern MRI will do the rest.

Fields marked * must be completed.
blue bullet Referring Clinicians Name
  Name not in list
blue bullet Surname *
blue bullet Forename *
blue bullet Date Of Birth*
(dd/mm/yyyy)
blue bullet Address *
blue bullet Postcode *
blue bullet Patients Telephone No.
This is important!
blue bullet Mobile No.
To speed up the appointment process
blue bullet Patients Email address
blue bullet Is the Patient Insured?
Yes     No
blue bullet Name of Insurance Provider
blue bullet Memb. No./Authorisation (If known)
blue bullet Please select the scan type by selecting one of the choices below.
     Other  
blue bullet Clinical Details / Further information (This information may be telephoned or mailed to the clinic in order to protect privacy or confidentiality)
blue bullet Address to which results / reports are to be sent

blue bullet Clinicians Email address
blue bullet Clinicians Mobile Tel. No.
blue bullet Please tick this box if you wish the report to be faxed to you
blue bullet Your Fax Number Please ensure this is a private & secure fax