Doctor Referral Form | PET/CT Diagnostic Imaging Services at Positron Diagnostics

THE CENTER
FOR PATIENTS
FOR DOCTORS
FAQ
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THE CENTER
FOR PATIENTS
FOR DOCTORS
FAQ
CONTACT US

DOCTOR REFERRAL FOR DIAGNOSTIC IMAGING SERVICES

We appreciate your confidence in our diagnostic imaging center for your patients’ advanced imaging needs, including PET/CT scans. Our team is committed to providing precise imaging services and prompt reporting to support you in delivering the best care to your patients.

To refer a patient for diagnostic imaging, please complete the referral form below. Please complete all sections to avoid any delays in setting the appointment. If you have any questions or require assistance, please contact us.

PATIENT INFORMATION

Name

Surname

Phone number

Biological Gender

ID/Passport number

Payment method

Please let us know how the patient plans to cover the cost of the appointment:

IMPORTANT SAFETY INFORMATION

Is the patient pregnant?

Yes

Is the patient breastfeeding?

Yes

Is the patient diabetic?

Yes (specify diabetic medication)

Latest fasting blood sugar

Any allergies?

Not sure

Yes (specify allergies)

Is the patient known to carry a high risk infection?

Yes (specify)

Is the patient claustrophobic?

Yes

Patient arrival needs

Is an interpreter required?

Yes (specify)

SPECIFY REASON FOR PET/CT STUDY

Type of cancer

Histologically proven

Suspected

Diagnosis to determine if suspicious lesion is cancer:

Pulmonary nodule

Other (specify)

Diagnosis to detect an occult primary tumour:

In patient with known/suspected metastatic disease

In patient with suspected paraneoplastic syndrome

Initial staging of confirmed, newly diagnosed cancer

Response to treatment

Suspected recurrence of a previously treated cancer

Site of suspected recurrence is:

Based on:

RECENT TREATMENTS DETAILS

Surgery Date

Surgery site

Other Previous Surgery/ies

Chemotherapy

Date of last treatment

Date of next treatment

Cycle Length

Radiotherapy

Site (field of radiation):

Combined (Chemo/RT)

Date of last treatment

Date of next treatment

Immunotherapy

Date of last treatment

Date of next treatment

Date of G-CSF (if applicable)

Other therapy (specify)

RECENT RELEVANT IMAGING

Previous PET/CT

Yes (enter date)

Previous CT

Date

Body Area

Previous MRI

Date

Body area

If this request is urgent, explain the reason

REFERRING CLINICIAN DETAILS

Name

Surname

Phone number

Address

Upload signed referral document/scan

I certify that the request is medically necessary for the care of this patient. All the above particulars furnished are true and correct.

The Center
For Patients
For Doctors
FAQ
Contact Us

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