Microsoft Word - PET Oncology Request Form 8-27-13



Please attach most recent Clinic NotePET/CT – Oncology Scheduling/Ordering RequestFax: 801-585-2314/Telephone: 801-587-4683Please attach most recent Clinic NotePatient Name MRN Date of Birth Sex: MF Physician Physician Phone Physician AddressZip Code Person Scheduling Physician Fax Cancer type**Location Histopathology ** If Patient has MELANOMA, LYMPHOMA, OR SARCOMA please give location **ICD-10 Diagnosis Date desired for PET/CT Scan: _______________384746521590000Reason for scan (check): Pulmonary Nodule Therapy monitoring StagingRestaging4732655-309880005838190-30988000Is Patient Diabetic? ____Yes___No Patient weight _____pounds Sedation required ______Yes ______NoClinical questions/Concerns: ________________________________________________494474526797000284226027432000206375014224000Prior PET/CT 170180014224000scans? Where? YesNoLast date performed//If Yes how many have been performed since 6/11/13Dates// //,//,// Prior CT scans? Yes NoWhen ? // Where? Patient Home PhoneWork Phone Patient Home AddressZip Code Patient Insurance Company Patient Policy # Pre-authorization # Insurance Company Phone # Patient Home PhoneWork Phone Patient Home AddressZip Code Patient Insurance Company Patient Policy # Pre-authorization # Insurance Company Phone # Provider Signature Owner: John Hoffman MD Version 8/25/16Provider NPI ____ ................
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