Online Appointment – IMRI LTD

Skip to content

Home
Team
News
Procedures
Services
Locations
Research
Contact
Book an Appointment

Make an Appointment

Home
Team
News
Procedures
Services
Locations
Research
Contact
Book an Appointment

Book an appointment

Your Personal Details

Title *

First Name *

Surname *

Email address *

Telephone *

Address Line 1 *

Address Line 2

Town / City *

Postcode *

Gender *MaleFemale

Are you involved in paid professional sports? *YesNo

Referral

Please provide details of your referring clinician for forwarding results of your investigation.

Are you *Referring YourselfBeing Referred

NHS Practice name *

NHS GP name *

NHS Practice Telephone

NHS Practice Email

Name *

Referring Clinician *

Telephone

Email

Address Line 1 *

Address Line 2

Address Line 2

Postcode *

Tell us about your condition

Examination

Select the examination required

I hereby consent to you sharing my information with my referring clinician. *I agree