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Nuclear Medicine Referral Form Scheduling # 4014447770 Fax # 4014447779PATIENT INFORMATION First Name:______Last Name: ___DOB:___ Primary Phone:MaleFemalePatient Weight :Insurance Plan:___(Needed
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How to fill out nuclear medicine order sheet

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How to fill out nuclear medicine order sheet

01
Begin by writing the patient's full name and identification number at the top of the sheet.
02
Specify the referring physician's name and contact information.
03
Indicate the type of nuclear medicine procedure being requested.
04
Fill in the clinical history or reason for the procedure.
05
Specify any relevant past medical history that may impact the procedure.
06
Include any allergies or contraindications related to the patient.
07
Indicate the preferred date and time for the procedure.
08
Check any additional instructions or special preparations needed for the patient.
09
Sign and date the order sheet to validate it.

Who needs nuclear medicine order sheet?

01
The nuclear medicine order sheet is needed by physicians who are referring patients for nuclear medicine procedures.
02
Nuclear medicine technologists require it to prepare for and conduct the imaging or therapeutic procedures.
03
Patients undergoing nuclear medicine exams need it for registration and preparation.
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A nuclear medicine order sheet is a specific document used by healthcare professionals to request nuclear medicine procedures, including diagnostic imaging and therapies involving radioactive substances.
Typically, physicians or qualified healthcare providers who prescribe nuclear medicine tests or treatments are required to file the nuclear medicine order sheet.
To fill out a nuclear medicine order sheet, the healthcare provider must provide patient details, specify the type of procedure, indicate the clinical indications, and complete any required signatures or date fields.
The purpose of the nuclear medicine order sheet is to formally document the request for nuclear medicine procedures, ensuring proper communication between the provider and the nuclear medicine department and facilitating patient care.
Information that must be reported includes patient demographics, the name of the referring physician, details of the requested procedure, clinical history, and any necessary special instructions regarding the patient’s condition.
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