Practitioner Booking Portal

Secure online radiology request form for healthcare professionals

For registered healthcare professionals only

All fields marked * are mandatory. Submissions are reviewed by our clinical team. A PDF copy will be emailed to you and to Radpid Diagnostics upon submission.

Section 1 — Patient Details

Title *

First Name *

Last Name *

Date of Birth * (DD/MM/YYYY)

Sex *

NHS Number (if known)

Phone *

Email *

Address *

Postcode *

Section 2 — Examination Requested

Type of Examination *

Examination Requested *

Section 3 — Clinical History & Justification

Clinical History / Reason for Referral *

Include relevant symptoms, duration, previous treatments, and clinical justification under IR(ME)R 2017.

Section 4 — Safety Questions

Section 5 — Referrer Details

Referrer Full Name *

Practice / Organisation *

Registration Type *

GMC Number *

Email *

Phone *

Section 6 — Declaration & Signature

Declaration

I confirm that I am a registered healthcare professional and that the clinical information provided is accurate to the best of my knowledge. I accept responsibility for this referral under IR(ME)R 2017 as the referrer.

Electronic Signature *

Sign here

Draw your signature in the box above using your mouse or touchscreen.

Date Signed *

Please complete all required fields before submitting.

By submitting this form you confirm the declaration above. A PDF copy will be sent to your email and to Radpid Diagnostics.