Positron Emission Tomography Form - State Of Gergia
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1
2Outpatient Scheduling Form
POSITRON EMISSION TOMOGRAPHY
To schedule FAX completed form to: (404) 778-5382, Voice contact: 404-778-4765 or 404-712-4453
Required information is indicated in BOLD, this request will be returned unscheduled, if incomplete.
Required information needed to schedule:
Patient Name (Last Name, First Name, MI):
Referring MD: _________________________________________
_____________________________________________________
NPI #: ____________________ PIC: ______________________
Medical Record Number: ________________________________
Fax: _______________________ Office Phone: ______________
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Date of Birth: _________________________
Male
Female
Office contact: _________________________________________
Weight: ________
: ________________________________
Patient’s Phone
(H/W/Cell)
Insurance Plan/FSC: ____________________________________
_____________________________________________________
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Member Insurance #: ___________________________________
Radiology to call patient to schedule exam?
Yes
No
ICD-9 Codes:
_______________________________________________________________________________________________
Diagnosis/Indications:
___________________________________________________________________________________
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❑
❑
❑
❑
❑
Prior FDG PET/CT exam:
Yes
No
Other Prior Imaging Studies (check all that apply):
CT
MRI
US
None
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❑
❑
❑
❑
❑
❑
Pregnant:
Yes
No
N/A
Diabetic / Renal Disease
Yes
No
Claustrophobic?
Yes
No
❑
❑
Requested Exam Date: ______________________________________________
Results needed for next appointment?
Yes
No
Next Appointment Date: ____________________________ Time: ___________
PET (PET/CT is routinely used for Tumor Imaging of the body.
Include Diagnostic CT with IV contrast
❑
This exam includes a non-contrast CT scan.)
Neck CT with IV contrast
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Brain PET
Chest CT with IV contrast
❑
❑
❑
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Seizure
Tumor
Dementia
Abdomen CT with portal phase IV contrast
❑
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Other: ___________________________________________
Pelvis CT with portal phase IV contrast
❑
Body PET (Tumor)
Please identify primary cancer:
Indication for diagnostic CT Scan(s):
❑
Breast
❑
____________________________________________________
Cervical
❑
Colorectal
❑
Esophageal
Additional clinical history and symptoms:
❑
Head & Neck
❑
Lung Nodule
❑
Lung Cancer
❑
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Lymphoma
CTCL
NHL
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Melanoma
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Multiple Myeloma
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Ovarian
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Other: ___________________________________________
Indication for PET Tumor Scan:
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Diagnosis (includes avoiding or directing biopsy)
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Initial treatment strategy
❑
Subsequent treatment strategy
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Other: ___________________________________________
Date: _________________ Time: _________________
Physician Signature
(MD, DO, NP, PA)
_________________________
____________
Scheduled Date:
Scheduled time:
AM / PM
Location:
87862
REQUE87862 1/11
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