Get the free PET SCAN REFERRAL FORM

This document is a referral form for patients needing a PET scan, outlining necessary patient information, clinical history, and insurance details required for scheduling the exam.

How to fill out pet scan referral form

How to fill out PET SCAN REFERRAL FORM

1. Obtain the PET Scan Referral Form from your healthcare provider or download it from the hospital's website.
2. Fill in the patient's personal information including name, date of birth, and contact details.
3. Provide the referring physician's details including name, specialty, and contact information.
4. Indicate the reason for the referral by selecting the appropriate clinical indications from the options provided.
5. Include any relevant medical history or conditions that may affect the PET scan or need to be considered.
6. Sign and date the form, ensuring that all required fields are completed.
7. Submit the completed form to the imaging center or hospital performing the PET scan.

Who needs PET SCAN REFERRAL FORM?

1. Patients who have been evaluated by a physician and require further diagnostic imaging for conditions such as cancer, neurological disorders, or cardiovascular diseases.
2. Individuals with symptoms or complexities that necessitate specialized imaging not provided by standard scans.

People Also Ask about

Can I self refer for a PET scan?

In most cases, a PET (Positron Emission Tomography) scan requires a referral from a doctor. This is because PET scans are typically used for specific medical purposes, such as diagnosing cancer, evaluating brain disorders, or monitoring treatment effectiveness.

Can I just ask for a PET scan?

Can You Request a PET/CT Scan? Yes, and we highly recommend doing so. If your doctor isn't willing to order you a PET/CT scan, you can contact us at CTOAM, and we will help you get one.

How much does a PET scan cost in England?

The cost of a PET-CT scan starts from £1,400. However, this price can change depending on the area of your body that needs to be scanned. This is because imaging larger areas or multiple parts of your body require several scans to be taken by an experienced radiographer or technologist.

How to prescribe a PET scan?

Discuss any recent illnesses, medical conditions, medications you are taking and allergies – especially to contrast material. Your doctor will likely tell you not to eat anything and to drink only water for several hours before your scan. Leave jewelry at home and wear loose, comfortable clothing.

What medication do they use for a PET scan?

For example, in PET scans of the brain, a radioactive atom is applied to glucose (blood sugar) to create a radionuclide called fluorodeoxyglucose (FDG), because the brain uses glucose for its metabolism. FDG is widely used in PET scanning.

What is the procedure for getting a PET scan?

During a positron emission tomography (PET) scan, you lie on a narrow table that slides into a doughnut-shaped hole. The scanner takes about 30 minutes to produce detailed images of metabolic activity in your tissues and organs.

How do you write a PET scan?

Positron emission tomography, also called PET imaging or a PET scan, is a type of nuclear medicine imaging.

How do you administer a PET scan?

You can expect the following during a PET scan: You'll receive an IV injection of a radiotracer that contains a safe amount of a radioactive drug. You'll sit in a chair for about an hour while the radiotracer moves through your bloodstream and gets absorbed by your organs and tissues.

For pdfFiller’s FAQs

What is PET SCAN REFERRAL FORM?

The PET Scan Referral Form is a document used by healthcare providers to refer patients for a positron emission tomography (PET) scan, which is an imaging test that helps to reveal how tissues and organs are functioning.

Who is required to file PET SCAN REFERRAL FORM?

Typically, healthcare professionals such as doctors, specialists, or physician assistants who are ordering a PET scan for their patients are required to file the PET Scan Referral Form.

How to fill out PET SCAN REFERRAL FORM?

To fill out the PET Scan Referral Form, the referring provider must complete sections detailing the patient's information, medical history, reason for the referral, and any specific clinical questions to be addressed by the PET scan.

What is the purpose of PET SCAN REFERRAL FORM?

The purpose of the PET Scan Referral Form is to ensure that the imaging facility has all necessary information to schedule, prepare, and execute the PET scan accurately and efficiently, and to facilitate communication between the referring provider and the imaging team.

What information must be reported on PET SCAN REFERRAL FORM?

The PET Scan Referral Form must include the patient's personal information, insurance details, the clinical indication for the scan, relevant medical history, the specific areas to be scanned, and the referring physician's contact information.