Scheduling an MRI scan at M24

Dear patient!

To make an appointment for an MRI, we suggest you fill out the form. Please note that some implanted foreign objects may be an absolute contraindication for MRI.

For this reason, we ask you to provide careful and accurate answers. If you do not know any answer while completing the questionnaire, you can provide it later when speaking with an M24 employee.

Please: keep in mind that the "Back" button at the bottom of the questionnaire window returns you to the previous block section of the questionnaire. However, the "Back" button in the browser will cause you to quit the form.

By providing your personal data in the questionnaire, you consent to it’s processing and use for the purpose of maintaining a personal data database and organizing the provision medical services and/or medical care.

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Email address *

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Last name *

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Name *

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Middle name *

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Date of birth *

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Height, cm *

Height must be more than 70cm and less than 250cm

Weight, kg *

Weight must be more than 15 kg and less than 150 kg

Patient's phone number (appointment-related service messages will be sent to this phone number) *

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Sex * male female

You must choose one option

Are you pregnant at the time of the study?* no yes

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Pregnancy term *

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Referring doctor’s full name

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Previous diagnosis (specified in the doctor's referral) or complaints (in the absence of a diagnosis)

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Have you had any surgeries in the examination area?* No Yes, less than a month ago Yes, more than a month ago

You must choose one option

Have you had any biopsies in the examination area? * yes no

You must choose one option

Do you (the patient) walk independently, without assistance? * Yes I move around with the help of crutches / a walker / a wheelchair I can't sit or walk on my own

You must choose one option

Which examination do you need? * I will copy from a doctor's referral I will choose from the list provided

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Name of the study indicated in the doctor's referral

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Please indicate any additional wishes regarding your appointment

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Completing the MRI exam registration form

I consent to the processing of personal data

I confirm that I have read and accept the terms of services the Public Contract (Offer) for the provision of medical services

Thank you, your application has been sent for processing.

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