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Nuclear Medicine Form
Diagnostic PET/ CT Form
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Home
Services
Forms
Nuclear Medicine Form
Diagnostic PET/ CT Form
Contact
PACS Portal
Diagnostic PET/CT Request Form
PET Scan Form
Patient Detials
Full Name
*
Date Of Birth
*
Gender
*
-- Please Select --
Male
Female
Address
Address
Address
Address
City
City
State
State
Postcode
Postcode
Phone
*
Diabetes
*
-- Please Select --
NO
IDDM
NIDDM
Diabetes
PET/CT EXAMINATION- Please tick. This is a Medicare Requirement.
*
PET with Whole Body Diagnostic CT (Brain, Neck, Chest, Abdo, Pelvis and Thighs) +/- Contrast
Plus Full Extremities (eg Melanoma, Sarcoma, Myeloma, Vasculitis, etc)
PET with Non-Diagnostic CT (attenuation correction)
Clinical Information
Diagnosis/ Staging/ Restaging/ Other
Primary Disease/ Site
Treatment
Contrast Allergy
Renal Impariment
eGFR
eGFR
Indications, MBS Elegible Items - Please Tick
Lung
Solitary Pulmonary Nodule (61523)
SSCLC- Staging (61529)
Gastrointestinal
Brain Tumour Recurrence (61538)
Epilepsy (61559)
Dementia (61560)
Gynaecology
Colorectal (61541)
Oesophageal/GEJ Staging (61577)
Brain
Ovarian- Recurrence (61565)
Uterine Cervix- Staging (61571)
Uterine Cervix- Recurrence (61575)
Melanoma
Restaging (61553)
Head and Neck
Staging (61598)
Residual (61604)
Metastatic SCC Cervical Nodes
Unknown Primary (61610)
Lymphoma
Staging (61620)
Therapy Response (61622)
Restaging (61628)
Post 2nd Line Chemo (61632)
Sarcoma
Staging (61640)
Residual/Recurrent (61646)
Breast
Locally Advanced (61524)
Suspected Mets/Recurrence (61525)
Rare/ Uncommon Cancer
Staging (61612)
Re-staging (61614)
PSMA
Prostate Ca- Staging (61563)
Prostate Ca- Recurrence (61564)
PSA:
Bx:
MBS INELIGIBLE ITEMS
Other FDG PET
Other FDG PET
Other PSMA PET
Other PSMA PET
Other
Other
Referrer Details
Full Name
*
Provider Number
*
Address
Address
Address
Address
City
City
State
State
Postcode
Postcode
Phone
Date
Signature
*
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