Parallel Imaging Solutions

PARALLEL IMAGING SOLUTIONS

MRI Referral Form

Private diagnostic imaging | Clinical referrers

DEMONSTRATION ONLY. Use fictional patient details. This form does not submit or store referrals, and its example codes are not secure authentication.

1. Referrer verification

Enter your approved referrer ID to begin. This prototype uses one fictional test account.

Referrer ID *

2. Patient details

Complete the patient's demographics and preferred contact details.

First name *

Surname *

Date of birth *

Contact number *

Patient email (optional) Address (optional)

3. MRI examination

Specify the examination required and any relevant scheduling information.

Region requested * Laterality Additional regions or protocol information

4. Clinical information and safety

Provide enough information for clinical vetting. MRI safety will require a separate formal screening process before scanning.

Clinical indication and relevant history * Known implants, devices, foreign bodies or previous surgery * If yes or unknown, provide details Other relevant information

5. Review referral

Review the information below. Submission is disabled in this prototype.

The live version will need secure server-side validation, verified clinician identity, compliant data handling and an auditable submission workflow.