PET/CT Referral Form Please fill out the form below. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient InformationName *FirstLastDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HeightWeightAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePatient Telephone NumberPatient Mobile NumberReferring Provider *Provider Telephone NumberProvider Fax NumberSigns and SymptomsType of CancerdiagnosedHistologically ProvenSuspectedCPT CodesIf provided a specific CPT code, please providePlease check RadiopharmaceuticalFDGPSMAInsurance InformationPrimary InsuranceSecondary Insurance Date Name Layout Designated Office Contact for Medical RecordsName *Phone NumberEmailTreatment StrategyCheck ONE and fill out corresponding section completelyInitial Treatment StrategySubsequent Treatment StrategyInitial Treatment StrategyDiagnosisInitial StagingOtherAbnormal finding ofBased onCheck OneTo determine whether the patient is a candidate for an invasive diagnosis or therapeutic procedure;To determine the optimal anatomic location for an invasive procedure; orTo determine the anatomic extent of the tumor when the treatment recommendations depend on the extent,Check OneTo determine whether the patient is a candidate for an invasive diagnosis or therapeutic procedure;To determine the optimal anatomic location for an invasive procedure; orTo determine the anatomic extent of the tumor when the treatment recommendations depend on the extent,Please list reason for scan here:(e.g., Alzheimer’s Disease)Subsequent Treatment StrategyRestagingMonitoring Tumor ResponseRestaging: After the completion of treatment (Check One)Status post the completion of treatment for the purpose of detecting residual diseaseDetecting suspected recurrence, or metastasis of previously treated cancer:Determine the extent of a known recurrencePET/CT is being used to potentially replace one or more imaging studies that (1) is being utilized to determine extent of known recurrence of (2) provided insufficient information for the clinical management of the patientLast date of treatment:MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Type of treatment:Site of suspected recurrence / metastasis:Based on:Confirmed by:Monitoring Tumor Response: During Treatment (Check One)ChemotherapyRadiotherapyOtherSpecifyPrescreening QuestionnairePregnantYesNoDiabetesYesNoPreviousCTMRIPET/CTWhereWhenPathologyYesNoWhereWhenRadiation TherapyYesNoProviderWhenChemotherapyYesNoProviderWhenAuthorized Treating Provider’s Signature Clear Signature NPI NumberDateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Submit
