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Imaging Request Form

This is an MRI Imaging request form for the exclusive use of Consultant Surgeons (orthopaedic, neurosurgery, neurology, pain management) and MSK Physicians. Please complete all necessary fields in order to facilitate an effective referral. All data provided will be strictly used for the purposes of the referral and will be processed according to GDPR guidelines.

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Enquiry form

We will respond to you within 24 hours or on the next working day, or please call 0203 195 2442.

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Date of Birth
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Stage one - Please fill out the details below.

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Stage two - Please confirm that the information below is correct and insert your payment details.

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Patient ID:
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Patient Email address:
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Patient Mobile number:
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Amount payable:
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Using our dedicated payment page is a safe and quick way to settle your invoice and will not save your card details on our system. Please contact the Fortius Billing Team on billing@fortiusclinic.com if you have any queries.

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Thank you for your payment. We will allocate the payment against your invoice within the next day. If you need a receipt, or have any queries, please don’t hesitate to contact us via email at billing@fortiusclinic.com

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