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First body area:

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

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What symptoms do you have in the first body area?

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Second body area scan:

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Third part body area scan

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Fourth part body area scan

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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?

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Do you have any of the following:

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Do you have kidney/renal impairment?

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Have you seen a GP or Consultant regarding this problem?

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Are you in good general health?:

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DEXA scan Colchester

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