Personal data

Name

Surname

Phone

I want a VAT invoice

NIP

Medical examination data

Type of examination

CITO extract (PLN 200)

Preferred date of the visit

Visit time

* I agree to the processing of my personal data by Ultra MR in order to answer the inquiry via email and / or telephone. More information on the processing of personal data can be found on the privacy policy page.

Additionally, I accept the online payment regulations. A planned visit for an MRI examination may be canceled no later than 24 hours before its date by contacting the reception desk of the facility where the visit was booked or by e-mail: info@ultramr.pl. If an e-visit is canceled less than 24 hours before the start of the examination, the fee for the service will not be refunded.

*I declare that I do not have any of the contraindications listed below:

pacemaker (especially the older type)
insulin pump
implanted hearing aid
neurostimulators
intracranial metal clips
metallic body in the eye
metal endoprostheses, sutures and foreign bodies in another location (e.g. iron filings in the eyeball, under the skin)
first trimester of pregnancy

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Personal data

Medical examination data