Please complete the form below and we will contact you as soon as possible.
Surname*
First Names*
Date of Birth*
Sex MaleFemale
Home Address*
Postcode*
Telephone*
Email Address*
Payment Self-payInsured
Insurance Company
Name of referring clinician
Examinations requested: Xray Ultrasound CT MRI Nuclear Medicine Intervention
Area to be examined
Clinical Details
Preferred location if known No PreferenceRoyal United HospitalBMI Bath ClinicCircleBath
Please enter the code below: