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Health Record #: Complete or place barcoded patient label here Patient Name: (Print first, last) dd mm by DOB: / / 596 Davis Drive Newmarket, ON L3Y 2P9q Females Malachi #: Version Code: Phone #:
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How to fill out nuclear medicine requisition

01
To fill out a nuclear medicine requisition, follow these steps:
02
Start by providing your personal information such as your name, date of birth, and contact information.
03
Next, indicate the reason for the test or procedure. Specify the type of nuclear medicine study required.
04
Provide relevant medical history, including any past surgeries, diseases, or conditions that may affect the test results.
05
If you are currently taking any medications, list them along with their dosage.
06
Indicate any allergies or known sensitivities to medications or substances used in nuclear medicine.
07
Specify the referring physician's name and contact details.
08
If you have health insurance, provide your insurance information, including policy number and group ID, if applicable.
09
Finally, sign the requisition form and date it to confirm your consent and understanding.
10
Ensure that all the required fields are filled in accurately and legibly to avoid any delays or misinterpretations.

Who needs nuclear medicine requisition?

01
A nuclear medicine requisition is typically needed by individuals who require diagnostic imaging studies or therapeutic procedures involving the use of radioactive materials.
02
The requisition is commonly used by referring physicians or healthcare providers to request specific nuclear medicine tests or treatments for their patients.
03
Patients who have symptoms or medical conditions that may benefit from nuclear medicine imaging, such as detecting tumors, assessing organ function, or evaluating blood flow, may be required to have a nuclear medicine requisition.
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A nuclear medicine requisition is a formal request for a nuclear medicine procedure, typically completed by a healthcare provider to initiate diagnostic imaging or therapy using radioactive materials.
Healthcare providers, such as physicians or specialists, are required to file a nuclear medicine requisition when referring a patient for a nuclear medicine procedure.
To fill out a nuclear medicine requisition, a healthcare provider should provide patient information, select the appropriate procedure, complete clinical history and indication for the study, and include any relevant medical records.
The purpose of a nuclear medicine requisition is to communicate the need for a specific nuclear medicine procedure, ensuring that the necessary information is provided for patient care and proper imaging or therapy management.
The information that must be reported includes patient demographics (name, age, gender), physician information, procedure requested, clinical history, reason for the study, and any prior relevant imaging studies.
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