Refer a patient

We accept referrals from a range of medical professionals, including GPs, hospital specialists, physiotherapies and chiropractors. Please use the form below to refer a patient to Berkshire Imaging. We will respond as soon as possible, within usual working hours, and take great care of your patient.

Patient Details

Patient Details*
Patient Details Required field
Drag and drop here or 
Max file size: 10 MB
Click to upload details - Please use landscape orientation

Patient Details

Patient Name
Patient Name
Gender
Gender
Date of Birth
Patient Address

Referrer Details

Have you registered as a referrer with us before?
Have you registered as a referrer with us before?
Referrer
Referrer
Referrer Address or Hospital

Study Details

Imaging Modality Required*
Imaging Modality Required Required field
If more than one examination is required, please submit separate forms for each
Could the patient be pregnant?*
Could the patient be pregnant? Required field

Signature

Referrer’s declaration:

This document is a legal document

The correct patient details have been given

I have discussed the examination with the patient / guardian

I have provided sufficient clinical information for the request to be justified according to current IR(ME)R regulations (for CT or X-ray examinations)

I will ensure the results are recorded in the patient’s notes

Date
30/09/2026
16:38
Signature
Use your mouse or finger to draw your signature above
Form secured by Formstack
Form secured byFormstack

Contact us

Telephone:
0118 338 2500
Email:
info@berkshireimaging.co.uk
Address:
Berkshire Imaging LLP
Arena 100 Berkshire Place
Wharfedale Road
Winnersh
Wokingham RG41 5RD.