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Patient Name: MAN: DOB: (Patient Label) Westwood:200MedicalPlaza,SuiteB114,Los Angeles,CA90095Phone:(310)7941005Fax:(310)2670227 Santa Monica:1245 16thStreet,Suite105,Santa Monica,CA90404Phone:(310)3194970

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How to fill out ucla petct request form

1. To fill out the UCLA PETCT request form, follow these steps:
2. Begin by providing your personal information, including your name, contact information, and date of birth.
3. Next, enter the details of the referring physician, including their name, contact information, and any specific instructions they may have given.
4. Specify the reason for the PETCT scan and any relevant medical history.
5. Provide information about any allergies or medical conditions you may have.
6. Indicate whether you have undergone any previous imaging or diagnostic procedures related to your current condition.
7. If applicable, include details about your insurance coverage and provide any necessary authorization information.
8. Finally, review the form for accuracy and completeness before submitting it.
9. Note: It is important to consult with your healthcare provider or the UCLA PETCT facility for any specific requirements or instructions regarding the form.

Who needs ucla petct request form?

1. The UCLA PETCT request form is typically needed by individuals who require a PETCT scan for diagnostic or monitoring purposes.
2. This may include patients with suspected or known cancers, individuals undergoing treatment or follow-up for cancer, or those being evaluated for certain medical conditions or diseases.
3. The form helps in ensuring proper communication between the referring physician, the PETCT facility, and the patient, thus facilitating the process of scheduling and conducting the PETCT scan.
4. Specific criteria for who needs to complete the form may vary based on the policies and procedures of the UCLA PETCT facility.

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What is ucla petct request form?

The UCLA PET/CT request form is a form used to request a positron emission tomography/computed tomography scan at UCLA.

Who is required to file ucla petct request form?

Patients who have been referred for a PET/CT scan at UCLA are required to fill out the request form.

How to fill out ucla petct request form?

To fill out the UCLA PET/CT request form, patients need to provide their personal information, medical history, reason for the scan, and any other relevant details.

What is the purpose of ucla petct request form?

The purpose of the UCLA PET/CT request form is to gather necessary information for scheduling and performing a PET/CT scan at UCLA.

What information must be reported on ucla petct request form?

The UCLA PET/CT request form requires information such as patient's name, date of birth, contact information, referring physician, reason for the scan, and any relevant medical history.