Private and Confidential

NI Radiology Referral Form.

Referrals can only be accepted from a medical professional.
Please complete this form clearly to help us process your referral promptly.

    Patient Details

    First Name:
    Surname :
    Mobile:

    Gender Identity:

    Gender Assigned at Birth:

    Address:
    Date of Birth:

    Self Payer:
    Private Health Insurance:

    Insurer Name:

    Examination Required

    Select Examination(s):
    Area to be Examined:
    Detailed Clinical Information:

    Previous Imaging:

    If Yes, please provide details:
    Mobility Aid Used:

    Referring Details

    Referrer Title:

    Referrer’s Name:
    Practice Name:
    GMC/HCPC:
    Other Professional No:
    Contact No:
    Email:
    Address:
    Signature:
    Upload Referral or Supporting Documents:

    Patient Safety

    •Please note that certain radiology examinations in pregnancy may put the unborn infant at risk.
    •For MRI, cardiac pacemakers, aneurysm clips, shunts, cochlear implants, intra-ocular implants, metallic foreign bodies, some surgical implants and early pregnancy are contraindicated.
    •Please indicate previous history of contrast reactions, allergies, medications, renal failures, liver disease, diabetes, etc.

    Comfort
    The foundation upon which Affidea has been built is trust. Both doctors and patients know that we strive to provide the best standard of care, delivered by the best professionals with the most modern technologies. Patients trust and rely on doctors. Doctors trust and rely on us.
    TRUST  
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    Network
    What’s Affidea’s secret to transforming the standards of healthcare service provision? Our people. Healthcare professionals that know what they are doing and care about what they do. They make us who we are today. And who we want to be tomorrow.
    PEOPLE  
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    Sharing
    We implement the highest standards and procedures to ensure safety. Affidea is committed to becoming the first European diagnostic provider to shape a new paradigm in patient safety by introducing a company wide Dose Excellence Programme ensuring the right balance between dose and image quality.
    SAFETY  
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    Safety
    Affidea has an extensive network of international affiliations with the world’s top medical institutions to ensure that our doctors always have immediate access to the latest medical knowledge, clinical guidelines and medical procedures in all Affidea medical centres in order to ensure the highest quality diagnostics and cancer treatment.
    NETWORK  
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    Trust
    We know that hospitality is important.  We care about how you feel and want to make each visit  to an Affidea centre as comfortable as we can.  An exceptional patient experience is ensured by delivering a personalised service in modern and comfortable service settings where you feel safe and confident that you are receiving the highest quality medical care.
    COMFORT  
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    Technology
    We develop and exchange best practice. Patients deserve to know what we do, how we do it and why we do it. The continuous improvement of all Affidea care delivery processes is achieved by capitalising on the company’s extensive experience in 14 European countries and an organised effort to share best practice to improve patient safety and patient experience.
    SHARING  
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    People
    Technology has done more for health today than it has ever done and will do even more in the future. Affidea is committed to operating a best in class medical equipment base and maintain it’s long standing relations with major equipment producers to ensure our patients will always have access to the latest, most innovative and effective technology.
    TECHNOLOGY  
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