Referral Form

Please fill out our form and one of our staff will get back to you as soon as possible. Patient instructions may be viewed in the "Patient Instructions for PET and CT Scans". Please note that PET/CT Fusion is now routinely performed on all "Body" PET Scans.

Patient Information
Today's Date
Name
Date of Birth
  Sex    Height    Weight
Home Phone
   Work Phone
Patient Appt.
Location (required)

Was a CT, MRI, or
PET scan done
on the patient in the
last 12 months?    
If yes, where?
   Results

Reason for Scan/Clinical Quest.
Relevant Medical & Surgical History




Physician Information

Name (required)
Specialty
Address
Phone
   Fax
Email (required)
Results




PET Scan

Type of PET/CT Fusion Scan Requested
Staging
Diabetes
If yes, what type of medication?

Recent Cancer Treatment


CT Scan

Head
Whole IAC's Temporal Bones Posterior Fossa
Orbital Maxillofacial Area (Sinuses)    

Spine
Cervical Lumbar
Thoracic    

Body
Neck Abdomen Chest
Pelvis Upper Extremity Lower Extremity

Contrast
None Contrast Only
With & Without Non-ionic Only
 


    
 

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