Get the free PETCT Patient Request Form - Alliance Medical UK

PET/CT Patient Request Form Please send completed request forms along with previous relevant imaging reports to: Alliance Medical Scene Center, Warwick Technology Park, Warwick, CV34 6DA Tel 0845

How to fill out petct patient request form

How to fill out a PET/CT patient request form:

1. Start by entering your personal information, including your full name, date of birth, and contact information. This ensures that the medical facility can easily reach you if they have any questions or need to provide updates regarding your appointment.
2. Next, provide your referring physician's details. This includes their name, medical facility or practice name, address, and contact information. It's important to accurately provide this information to ensure that the results of your PET/CT scan are sent to your referring physician correctly.
3. Indicate the reason for the PET/CT scan. This could include a specific medical condition or symptoms you are experiencing that require further investigation. Be as concise and detailed as possible in this section to ensure the healthcare professionals can effectively evaluate your case.
4. If applicable, provide any relevant medical history or current medications you are taking. This section is vital for healthcare professionals to understand your overall health status and potentially make adjustments during the scan procedure.
5. Specify any known allergies or sensitivities you have. This is crucial to ensure your safety during the procedure, as certain contrast agents or medications used during PET/CT scans may cause adverse reactions in individuals with specific allergies or sensitivities.
6. If you have had any previous PET/CT scans or other relevant imaging tests, provide a brief summary of the findings and dates they were performed. This helps the radiologist compare past results with your current scan and track any changes over time.
7. Lastly, sign and date the form to acknowledge that you have provided accurate and truthful information to the best of your knowledge. By signing, you also grant consent for the medical facility to perform the PET/CT scan and share the results with your referring physician.

Who needs a PET/CT patient request form:

The PET/CT patient request form is necessary for individuals who require a PET/CT scan for diagnostic purposes. This can include patients who are suspected of having cancer, need staging for cancer treatment, or require assessment of treatment response. The form ensures that all necessary information about the patient, their referring physician, and the reason for the scan is obtained, enabling healthcare professionals to provide optimal care and treatment planning.

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What is petct patient request form?

The PET/CT patient request form is a document used by healthcare providers to initiate and authorize a positron emission tomography/computed tomography (PET/CT) scan for a patient.

Who is required to file petct patient request form?

Typically, the referring physician or healthcare provider who is ordering the PET/CT scan is required to file the PET/CT patient request form.

How to fill out petct patient request form?

To fill out the PET/CT patient request form, the healthcare provider must provide patient information, diagnosis details, clinical history, and reason for the scan, and sign the form.

What is the purpose of petct patient request form?

The purpose of the PET/CT patient request form is to ensure that all necessary patient and clinical information is documented to facilitate the appropriate imaging procedure and ensure proper patient care.

What information must be reported on petct patient request form?

The PET/CT patient request form must report information such as patient demographics, referring physician details, clinical history, indications for the scan, and any previous imaging results if applicable.