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CLINICAL PET REQUISITION FORM

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  • pg 1
									                                                                                   Toll Free: 1-866-JHU 4 PET
                                                                                               (1-866-548-4738)
                                                                                          Local: (410) 955-7226
                                                                                             Fax: 443-287-2557
Nuclear Medicine/PET, 600 N. Wolfe St. Nelson B1-150 Balto. MD 21287                         Fax: 410-955-0162
                                                                                   For Official Use Only
                                                                                      Date/Time of Study
CLINICAL PET REQUISITION FORM


Name: ______________________________________________________________________________________
Address: ___________________________________________________________________________________
City/State/Zip: _______________________________________________________________________________
Tel. Nos.: Home: ____________________ Work:____________________ Cell:___________________________
For JH For IN-PATIENT: Hx #__________________SSN:________________Location:___________________
Sex: _____ Date of Birth: ________________ Height: _____________ Weight: __________________ (lbs)
Mother’s maiden name (first, last) (omit if JHH Hx # is provided)______________________________________
Father’s name (first, last) (omit if JHH Hx # is provided)_____________________________________________
Referring Physician: (PRINT)___________________________ Tel: _______________ Fax: ________________

Clinical Dx/Relevant Findings:_________________________________________________________________
___________________________________________________________________________________________
_
___________________________________________________________________________________________
_

Indication   : □     Diagnostic   □   Staging    □   Restaging   □   Therapy Assessment

Prior Therapy:   □     Radiation Therapy        Date: _______________________

                 □     Chemotherapy             Date: ________________________

                 □     Surgery                  Date: ________________________

History of Diabetes:   □   No     □   Yes             Claustrophobic?     □   No    □     Yes

Last CT/MRI Date: _________________________ Performing Facility: _________________________________
Result of last CT or MRI: ______________________________________________________________________
___________________________________________________________________________________________
_
Please send latest film/report(s) with patient
INSURANCE INFORMATION: (Must fill out ALL information or we will return request back)
Company Name: __________________________________________________ Tel: _______________________
Address: ____________________________________________________________________________________
Cardholder’s Name: ___________________________________________________________________________
Patient’s Group Number: _________________________ Membership Number: __________________________
 PLEASE PHOTOCOPY FRONT & BACK OF MEDICAL CARD FOR VERIFICATION

								
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