Patient name *
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Address
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Diabetes *—Please choose an option—NOIDDMNIDDM
Diabetes details *
PET with Whole Body Diagnostic CT (Brain, Neck, Chest, Abdo, Pelvis and Thighs) +/- ContrastPlus Full Extremities (eg Melanoma, Sarcoma, Myeloma, Vasculitis, etc)PET with Non-Diagnostic CT (attenuation correction)
Diagnosis / Staging / Restaging / Other
Primary Disease / Site
Treatment
NotesContrast AllergyRenal ImpairmenteGFR
eGFR value *
LungSolitary Pulmonary Nodule (61523)SSCLC- Staging (61529)
GastrointestinalColorectal (61541)Oesophageal/GEJ Staging (61577)
GynaecologyOvarian- Recurrence (61565)Uterine Cervix- Staging (61571)Uterine Cervix- Recurrence (61575)
BrainBrain Tumour Recurrence (61538)Epilepsy (61559)Dementia (61560)
MelanomaRestaging (61553)
Head and NeckStaging (61598)Residual (61604)
Metastatic SCC Cervical NodesUnknown Primary (61610)
LymphomaStaging (61620)Therapy Response (61622)Restaging (61628)Post 2nd Line Chemo (61632)
SarcomaStaging (61640)Residual/Recurrent (61646)
BreastLocally Advanced (61524)Suspected Mets/Recurrence (61525)
Rare / Uncommon CancerStaging (61612)Re-staging (61614)
PSMAProstate Ca- Staging (61563)Prostate Ca- Recurrence (61564)
PSA
Bx
MBS Ineligible ItemsOther FDG PETOther PSMA PETOther
Other FDG / PSMA / Other details
Referrer name *
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