Cardiac MRI request

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Cardiac MRI request

Email *

Referrer's NAME *

Patient's FULLNAME *

Patient's DATE OF BIRTH *

YYYY

Patient's TELEPHONE *

Patient's EMAIL or other contact details *

Self-paying or Insured *

Preferred Cardiac MRI protocol *

As per Dr Cheong's recommendation (based on clinical question provided)

Cardiac structure and function

Heart failure aetiology

Assessment for myocardial ischaemia

Family history of cardiomyopathy

Assessment for myocarditis

Right heart assessment

Pericardial assessment

Valve assessment

Other:

Clinical history / indication / question *

Chest discomfort / ischaemia

Breathlessness / cardiomyopathy

Exercise induced palpitations / dizziness / syncope

Valvular heart disease

Cardiomyopathy ? viability study

Other:

Pacemaker / other metal device in-situ? *

Other foreign body (ie. cerebral clips / metal fragments) *

Pregnancy? *

Asthma? *

Chaustrophobia? *

Preferred procedure location *

London

Kent

Required

Any other relevant information (or please forward clinic letter / other documents to enquiries@jcheong.com)

Provide insurance number (if applicable)

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy