Pet Scan Request Form printable pdf download

Lebanon

Lancaster

PET Scan Request Form

Date of procedure: ____________ Time: ___________ Nursing

___________ Injection

Phone: (603) 650-5560

___________ Scan

Fax: (603) 650-4643

MUST CHOOSE ONE

Initial treatment (formally diagnosis & staging)

Patient name: ______________________________________________

Subsequent treatment (formally restaging and monitoring

response to treatment)

MRN: ________________________ DOB: ______________________

Male

Patient’s phone #: ____________________________________________

Female

If patient is female and of child bearing age (13-50):

Requesting physician: _________________________________________

Is there a possibility of pregnancy?

Yes

Is the patient breastfeeding?

Yes

Physician’s phone #: __________________________________________

For all oncology patients aged 18-40, an oral Xanax dose of 0.5mg will be administered by a radiology nurse 1 hour prior to the PET

scan. This is to minimize muscle and brown fat activity seen on the PET scan. A driver must accompany the patient and remain through

all appointments.

Please check here if you do NOT want your patient to receive Xanax 0.5mg orally 1 hour prior to the PET scan.

Indication for study: Please give a description of the disease and the reason for this test. Include details (e.g., of breast cancer, which

breast?) and history of prior surgery for this disease: _________________________________________________________________________

______________________________________________________________________________________________________________________

Please specify which type of PET is requested:

Standard (includes neck, chest, abdomen, and pelvis) (78815)

Brain only (dementia, seizures, brain tumor) (78608)

Standard plus head and neck (for head/neck cancer) (78815)

Cardiac viability (78459)

Entire body, head to toes (for melanoma or where clinical

Cardiac perfusion (single 78491)

concern is in extremities) (78816)

Cardiac perfusion (multiple 78492)

Approved by: ___________________________________________

Additional instructions for technologist: __________________________________________________________________________________

______________________________________________________________________________________________________________________

Has this study been pre-certified

Yes

Pre-cert # _____________________ Exp. ___________ CPT Code _______________

Name of insurance plan: ______________________________________ Insurance representative’s name: ____________________________

Has this patient had a prior PET scan

Yes

No If yes, which facility: ____________________________________________________

Specifically related to this disease process, has this patient had:

Any prior x-rays

Yes

No If yes, which facility: _____________________________________ Date: ___________ Time: __________

Any prior CTs

Yes

No If yes, which facility: _____________________________________ Date: ___________ Time: __________

Any prior MRIs

Yes

No If yes, which facility: _____________________________________ Date: ___________ Time: __________

If patient has outside films, they:

Hand carry

Were sent

Are here

Does patient have any allergies

Yes

No If yes, please list: ___________________________________________________________

Is there a problem with claustrophobia

Yes

Is this patient a diabetic

Yes

Insulin? ____________

Oral medication ____________

Patient’s height: _______________

Patient’s weight: _______________

Scheduled by: _________________________________________________________________________ Date:

________________________

One Medical Center Drive | Lebanon, NH 03756 | Tel: (603) 650-5000 |

Rev. 5-17-10

Pet Scan Request Form

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