Get the free PETCT REFERRAL bFORMb - cedars-sinaiprod csmc

PET/CT REFERRAL FORM To schedule, please call: (310) 4238000 Please fax all orders to: (310) 4230137 Physicians SIGNATURE REQUIRED Patient Name: Date of Birth: MONTH/DATE/YEAR Confirmation Number

How to fill out petct referral bformb

How to fill out PET/CT referral form?

Begin by providing your personal information:

1. Fill in your full name, contact number, and date of birth.
2. Include any relevant identification numbers or medical record numbers provided by your healthcare provider.

Mention the referring physician:

1. Write the complete name and contact information of the healthcare professional who is referring you for the PET/CT scan.
2. Include the physician's specialty or department, if applicable.

Provide patient details:

1. Write the patient's full name, contact number, and date of birth (if different from the referring physician's information).
2. Specify the patient's gender and any known allergies or previous adverse reactions to contrast agents or medications.

Indicate the reason for the referral:

1. Specify the purpose of the PET/CT scan, such as cancer staging, treatment response evaluation, or diagnosis.
2. Include any relevant clinical indications or symptoms that justify the need for the scan.

Include relevant medical history:

1. Provide a brief medical history, including any current medical conditions, previous surgeries or interventions, and relevant laboratory or imaging results.
2. Mention any ongoing treatments or medications that could potentially interfere with the scan.

Specify the desired radiopharmaceutical or isotope:

1. Indicate the desired tracer or radiopharmaceutical that should be used for the PET portion of the scan.
2. If you are unsure, leave this section blank, and the nuclear medicine technologist or radiologist will determine the most appropriate radiopharmaceutical based on your specific case.

Additional instructions or questions:

If you have any specific instructions for the scanning facility or any questions you may have regarding the PET/CT procedure, you can include them in this section.

Who needs PET/CT referral form?

Patients requiring PET/CT scans for diagnostic or treatment purposes:

1. Individuals suspected or diagnosed with cancer who require staging or monitoring of treatment response.
2. Patients with neurological disorders, such as epilepsy, Alzheimer's disease, or brain tumors.
3. Those with cardiovascular diseases, like myocardial viability assessment or detection of infective endocarditis.

Physicians or healthcare professionals referring patients for PET/CT scans:

1. Oncologists, hematologists, or other specialists involved in the diagnosis and treatment of cancer.
2. Neurologists or neurosurgeons evaluating patients with neurological conditions.
3. Cardiologists or cardiac surgeons overseeing the management of cardiovascular diseases.

Remember, accurately completing the PET/CT referral form is crucial to ensure the appropriate scan is performed and to provide the necessary information for a comprehensive interpretation of the results. Always consult with your healthcare provider for any specific instructions or requirements.

For pdfFiller’s FAQs

How do I execute petct referral bformb online?

Completing and signing petct referral bformb online is easy with pdfFiller. It enables you to edit original PDF content, highlight, blackout, erase and type text anywhere on a page, legally eSign your form, and much more. Create your free account and manage professional documents on the web.

How do I make changes in petct referral bformb?

The editing procedure is simple with pdfFiller. Open your petct referral bformb in the editor, which is quite user-friendly. You may use it to blackout, redact, write, and erase text, add photos, draw arrows and lines, set sticky notes and text boxes, and much more.

Can I sign the petct referral bformb electronically in Chrome?

Yes. You can use pdfFiller to sign documents and use all of the features of the PDF editor in one place if you add this solution to Chrome. In order to use the extension, you can draw or write an electronic signature. You can also upload a picture of your handwritten signature. There is no need to worry about how long it takes to sign your petct referral bformb.

What is petct referral bformb?

Petct referral bformb is a form used to refer a patient for a PET-CT scan.

Who is required to file petct referral bformb?

Medical professionals such as doctors or specialists are required to file petct referral bformb.

How to fill out petct referral bformb?

To fill out the petct referral bformb, the medical professional must provide patient information, reason for referral, and any relevant medical history.

What is the purpose of petct referral bformb?

The purpose of the petct referral bformb is to request a PET-CT scan for a patient in order to diagnose or monitor a medical condition.

What information must be reported on petct referral bformb?

The petct referral bformb must include patient demographics, reason for referral, relevant medical history, and any specific instructions.