1. No category

Patient label here or information below is required
Last Name
First Name
PET/CT Imaging Request
Birthdate (yyyy-Mon-dd)
Gender o Male
o Female
Address (street, city, province, postal code)
< Fax to Diagnostic Imaging; fax numbers listed at
http://www.albertahealthservices.ca/diagnosticimaging
< Urgent/Emergent requests must be Preferred Facility
discussed by direct consultation with
No Preference
the radiologist
Referring Physician (Print first and last name)
Signature
Date (yyyy-Mon-dd)
PHN
Inpatient location
Physician Phone
Daytime Phone
WCB Claim Number
Physician Fax
Copy to Physician (first and last) Copy to Fax
Specific anatomical area to be examined/name of exam
Diagnostic CT
o Yes
o No
Relevant clinical history/presumptive diagnosis
Clinical question to be answered
Relevant Previous Imaging Studies
Location
Type
Previous Treatment
Treatment
Radiotherapy
Chemotherapy
Marrow Stimulant Therapy
Other, specify:
Surgery/Biopsy
Date (yyyy-Mon-dd)
No
Yes If Yes:
Start Date (yyyy-Mon-dd)
Specify procedure:
Current Patient Condition
Condition
No Yes If Yes:
Diabetes
Allergies
Specify:
Date of LMP:
Pregnant
o n/a
Claustrophobia
Driver needed if patient given Ativan
Renal insufficiency
Research Study
Study name:
Nuclear Medicine Physician Only Date format: yyyy-Mon-dd - Time format: hh:mm
Date Received
Time Received
Appointment Date
Priority
o OP1
o OP2
o OP4, Specify date:
19032 (2014-09)
o OP3
Protocol
Attached copy
o No
o Yes
Completion Date (yyyy-Mon-dd)
Date:
Study Number:
Appointment Time
Radiologist