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Nuclear Medicine Form
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Nuclear Medicine
Nuclear Medicine
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Bone Scan
Myocardial Perfusion Scan
Gated Heart Pool Scan
Cardiac Amyloid Scan
VQ Lung Scan
Lymphoscintigraphy
Brain Scan
Thyroid Scan
Other Nuclear Med Studies
Oesophageal Transit and Reflux Study
Gastric Emptying Study
White Cell Scan
Red Cell Scan / GI Bleed Study
Meckel’s Scan
MAG-3 Renal Scan
DMSA Renal Scan
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BMD
BMD
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Age 70 or older (12323)
Fracture after minimal trauma or monitoring of OP (12306)
Prolonged and current glucocorticoid therapy or hypogonadism (12312)
Chronic medical conditions (12315)
12 months following significant change in therapy (12321)
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