THE CENTER
FOR PATIENTS
FOR DOCTORS
FAQ
CONTACT US
Book PET/CT Scan
EN
GR
THE CENTER
FOR PATIENTS
FOR DOCTORS
FAQ
CONTACT US
APPOINTMENT REQUEST
Please complete the below information and we will get back to you in regards to your appointment request.
If you are a doctor referring a patient,
go to the Doctor's Referral Form
PATIENT INFORMATION
Name
Surname
Email
Phone number
Biological Gender
Select gender
Female
Male
ID/Passport number
Payment method
Please let us know how you plan to cover the cost of your appointment:
GESY
Private Insurance
Self-Payment
IMPORTANT SAFETY INFORMATION
Is there a pregnancy possibility?
No
Yes
Are you breastfeeding?
No
Yes
Are you diabetic?
No
Yes (Specify diabetic medication)
Any allergies?
No
Not sure
Yes (Specify allergies)
Are you claustrophobic?
No
Yes
State any arrival needs
Select
None (walking)
Trolley
Wheelchair
SPECIFY REASON FOR PET/CT STUDY
Type of cancer
RECENT TREATMENT DETAILS
Surgery Date
Surgery Site
Other Previous Surgery/ies
Other therapy (specify)
REFERRING CLINICIAN DETAILS
Name
Surname
Phone number
Email
Upload doctor referral
The information shared are true and correct. Positron Diagnostics can contact me and/or my doctor for additional necessary information
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