Enquiry Form

Which scan would be best for you?

If you are unsure which scan would be most appropriate for you, please complete the below form and you will be contacted shortly with feedback.


1) Which scan(s) would you like to have? (Tick all that apply)
Available CT Scans:
Heart   Bone mineral density (BMD)
Lung   Coronary angiogram*
Abdominal and pelvic*   Virtual colonoscopy

* = Doctor referral necessary
 
Available Ultrasound Scans:
Prostate   Testes
Abdominal Aorta Aneurysm Carotid Doppler (neck arteries)
Female reproductive organs    

2) Other enquiries:

3) Please briefly summarise your reasons for having this particular scan(s)? (symptoms, family history, peace of mind etc)

4) Please mention any investigations or consultations over the last five years? (if any)

5) Your Contact Details

*Title:

   *Surname:
*First Names:   *D.O.B: e.g. DD/MM/YYYY
Address:  
   
   
Postcode:      
*Telephone:
(Daytime)      
Mobile:      
E-mail:

* = mandatory


 
European Scanning Centre
68 Harley Street | London W1G 7HE
T: 020 7436 5755