REFERRAL FOR CT SCAN

Please complete the form below and click on the "send referral" button to send this information electronically to us.

Practitioner Details

Treatment Requested

Name: *

Detailed description of request for scan

Address:

 

Clinic Name

Is this request urgent?

yes no

Telephone:

Email:*

Relevant Clinical details

Patient Details

Name: *

Specific Area of Interest

Parent's Name if Applicable:

(details)

Address:

 

Date of Birth (dd/mm/yy):

Please note: A scan will not be processed if the above information is not relevant. Following receipt of this referral your patient will be contacted for an appointment. The fee for CT Scan is €250. We will forward the scan to you on a disc with manipulation software downloadable.

Daytime Telephone: *

Evening Telephone: *

Email:*

* Required field.