Get the free PET CT Request Form V2 - Qscan

PET/CT REQUEST PRIOR TO APPOINTMENT FAX OR EMAIL THIS FORM pH: 07 5503 3433 Fax: 07 5503 3444 Email: PET×qscan.com.AU Dr Eric Slaves 19732016 Dr Hal Rice Dr David Legged Dr Mark Hansen Dr Stephen

How to fill out pet ct request form

How to fill out pet ct request form

1. To fill out a PET-CT request form, follow these steps:
2. Start by providing your personal information, including your name, contact details, and date of birth.
3. Indicate the specific reason for your PET-CT scan, whether it is for diagnostic or monitoring purposes.
4. Provide details about your medical history, including any previous illnesses, surgeries, or ongoing treatments.
5. Mention any allergies or adverse reactions you may have to medications or contrast agents.
6. If you are taking any medications, list them along with their dosage and frequency.
7. Specify any pre-existing conditions or comorbidities that may be relevant to the scan.
8. Indicate whether you have any implants, such as pacemakers or prosthetic devices, as they may interfere with the scan.
9. Provide information about any recent X-rays or other imaging studies related to the same medical condition.
10. If applicable, provide details about your insurance coverage and policy information.
11. Finally, sign and date the form to authorize the request for a PET-CT scan.
12. Make sure to double-check all the entered information for accuracy before submitting the form.

Who needs pet ct request form?

1. The PET-CT request form is needed by individuals who require a PET-CT scan for diagnostic or monitoring purposes.
2. This may include patients with suspected or confirmed cancer, individuals undergoing cancer treatment,
3. and those with certain neurological or cardiovascular conditions.
4. The form helps healthcare professionals gather essential information about the patient's medical history,
5. current health status, and any specific requirements or considerations for the scan.
6. It ensures that the PET-CT scan is performed safely and effectively,
7. with the necessary precautions taken based on the individual's medical background.
8. Ultimately, anyone who needs a PET-CT scan should fill out the PET-CT request form as part of the standard process.

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What is pet ct request form?

The pet ct request form is a document used to request a PET/CT scan for medical purposes.

Who is required to file pet ct request form?

Any patient or healthcare provider who wants to request a PET/CT scan must fill out the form.

How to fill out pet ct request form?

The form can be filled out by providing the patient's information, medical history, and reason for requesting the PET/CT scan.

What is the purpose of pet ct request form?

The purpose of the form is to gather necessary information for healthcare providers to determine if a PET/CT scan is necessary for the patient's diagnosis and treatment.

What information must be reported on pet ct request form?

The form typically requires information such as patient's name, date of birth, medical history, reason for the scan, referring physician, and insurance information.