DEXA scan Manchester

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Please select the type of scan:

You have selected a DEXA scan. How many parts of the body do you need scanned?:

Name:

First Last

Date of birth (dd/mm/yyyy):

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Mobile number:

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Address:

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Do you have a referral letter for the above scan?:

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Please provide some additional information, so our medical team can provide a referral for your scan:

Thank you for your payment.

Please provide some additional information, and upload your referral letter:

GP name / Doctor's name:

Surgery name:

Legal guardian

Mobile number:

Gender

Height/units

Weight/units

First body area:

How long have you been complaining of symptoms in first body area?:

(period)

What symptoms do you have in the first body area?:

Difficulty in moving

Dull ache

Feeling generally unwell

Headache

Limitation of movement

Limping

Numbness

Pain - sharp

Pins and Needles

Stiffness

Swelling

Weakness

Please provide more details about your selected body area scan:

Second body area scan:

Second body area symptoms:

How long have you been complaining of symptoms in second body area?

(period)

Third part body area scan

Third body area symptoms

How long have you been complaining of symptoms in third body area?

(period)

Fourth part body area scan

Fourth part body area symptoms

How long have you been complaining of symptoms in fourth body area?

(period)

Please provide more details

Referral letter

Surgery/Clinic name

Surgery/Clinic phone if available

Please upload here the referral letter file:

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

Please note the referral letter should:

be issued by a registered GP, Doctor, Consultant, Specialist, Physiotherapist or Osteopath;

contain the patient’s full name and date of birth;

specify the indications or symptoms, the type of scan requested and the body area(s) to be scanned;
be signed and show the GMC or other registered number of the referring party.

Other medical information

Please answer the questions below:

Have you had any surgery in the last 8 weeks?

Do you have a cardiac pacemaker?

Do you have any metal implants or prostheses?

Do you have any metal fragments in the eye?

Are you pregnant?

Are you breast feeding?

Do you suffer from claustrophobia?

Do you have an aneurism clip?

Do you have any of the following:

Allergies

Asthma

Depression

Diabetes

Epilepsy

Heart disease

High blood pressure

Do you have a cochlear implant or neurotransmitter?

Do you have a programmable ventriculoperitoneal shunt?

Do you have kidney/renal impairment?

Have you seen a GP or Consultant regarding this problem?:

Yes

Please provide details

Are you in good general health?:

Yes

Please provide details

Have you had any injuries or accidents?:

Yes

Please provide details

Have you had any operations or scans?:

Yes

Please provide details

Are you taking any medication or tablets?:

Yes

Please provide details

Other relevant details or family history:

Do you have any comments or special requests?

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By submitting this form:

I agree to Secure Scanners Terms & Conditions.

I also consent to my symptoms and medical history being reviewed by the medical team who may contact me for further details and will recommend an appropriate scan or test.

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You selected a DEXA scan in Manchester

DEXA Altringham, Manchester

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You can pay here for your appointment

Thank you.

Please provide some additional information, so our medical team can provide a referral for your scan:

Thank you for your payment.

Please provide some additional information, and upload your referral letter:

Referral letter

Other medical information

Secure Scanners Limited

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