ࡱ> KMJM  bjbj== .*WW l(((((((\V V V 8 $ <\2        giiiiii$ :(     6 ((  6 6 6  :( ( g6  g6 6 /(({ 4^\V J G{0O,, {6 <N(((( PET/CT REFERRAL FORM FAX REQUESTS TO: 01- 4284137 St. Jamess PET CT Centre, 188 1 Ground Floor. Tel (353 1) 428 4947 Email  HYPERLINK "mailto:PetCT@stjames.ie" PetCT@stjames.ie Purchase Order Num: _________________ 1. PATIENT DETAILS Patient Name ________________________________________________ MRN:________________________________________ D.O.B: ___________________________________ Male ( Female ( Address_________________________________________________________________________________________________________ HOME PHONE: ___________________________________ MOBILE PHONE: ____________________________ 2. REFERRING CLINICIAN Referring Clinician._____________________________________________ referring hospital__________________________ clinician contact phone/e-mail___________________________________ Fax number for report: _____________________ Medical Insurance : ___________________Medical Insurance No. _________________________ Plan Type _____________ 3. SPECIFY STUDY AND Indication Diagnosis and History: Histologically Proven: Yes ( No ( SCAN TYPE: FDG PET/CT standard oncology body ( total body oncology (melanoma/myeloma) ( brain ( other (discuss in advance) ( REASON FOR PET/CT Diagnosis ( Staging ( Restaging after Therapy ( Monitoring Response ( Suspected Recurrence (Date Last: Surgery ________________________________________ Chemotherapy __________________________________ Radiotherapy _________________________________ G-CSF (if applicable)____________________________isolation/precautions (MRSA/c. diff/ tb etc.): pregnant/breast feeding: Yes ( No ( Lmp Date : Creatinine Level ______________________DATEDiabetic Yes ( No (HistorywhenwherePrevious PET/CT Yes ( No (Previous CT/ MRI Yes ( No ( Instruction for referring doctor & patient Low carbohydrate diet on day before study. Drink only water on day of scan. All In-patients must have IV Cannula placed. No food after midnight of study before 1pm. No food after 7am if study is after 1pm Stop TPN/ IV Dextrose at midnight before study. 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