PET/CT SCAN ORDER FORM - Medical City Dallas Hospital

PET/CT SCAN ORDER FORM
Scheduling: 972-566-EXAM (3926) Fax: 1-866-743-2104 Date of Order: ___________________________
Images: Di-com CD JPEG CD Printed Images Send w/Patient To be picked up Other
For Images marked other please contact our PET SCAN/Nuclear Medicine Department at 972-566-7030
PATIENT: ________________________________________________
SOCIAL SECURITY #: ___________________________________
DATE OF BIRTH: __________________________________________ Circle One: Male Female Height_______ Weight_______
DIAGNOSIS: _____________________________________________ _ Reason For exam(Circle one): Diagnosis Staging Restaging
INSURED NAME: __________________________________________
EMPLOYER OF INSURED: __________________________________
INSURED’S SOCIAL SECURITY #: ____________________________
Other reason:_______________________________________
INSURED
PHONE:
HOME: ____________________________________
WORK: ____________________________________
MOBILE: ___________________________________
INSURANCE COMPANY: ____________________________________
INSURANCE PHONE #: _____________________________________
GROUP NAME: ____________________________________________
DOCTOR’S NAME: _________________________________________
INSURED ID #: _________________________________________
GROUP NUMBER: ______________________________________
DR FAX NUMBER: ______________________________________
DR PHONE NUMBER: _______________________________________
PHYSICIAN’S SIGNATURE: _______________________________________________________Time______________Date_____________
_______________________________________________________________________________
SEDATION NEEDED: YES NO
HEART: BRAIN: ONCOLOGY:
FDG VIABILITY EPILEPSY WHOLE BODY(Melanoma or any CA below knees)
EEG (if needed)
SKULL BASE TO MID-THIGH
TUMOR
STROKE
ALZHEIMER
Comments: _________________________________________________________________________________________________________________
Is the patient Diabetic YES NO
If patient is diabetic, are they on insulin List amount: YES: Insulin Amount ___________ NO
Has the patient had a stroke in the last 3 months YES NO
Does the patient have asthma YES NO
Is the patient taking theophylline/inhalers containing theophylline YES NO
Has the patient had prior PET or CAT Scans YES NO
Can the patient bring CT/PET Scans Day of PET Scan YES NO
Other Medications: ___________________________________________________________________________________.
DR TO READ: ____________________________________________
APPOINTMENT DATE: ______________________________
COMPLETED BY: __________________________________________
APPOINTMENT TIME: _____________________________
DATE: _______________________
Person who scheduled: ___________________________ Date scheduling done: _______________ Time scheduling done: _________________

PET/CT SCAN ORDER FORM
Please Note: Females of childbearing potential must have a negative pregnancy test if more than ten (10) days since the last menstrual cycle.
For More Information about Your Procedure visit us at: www.medicalcityimaging.com
Medical City Imaging at
Medical City Dallas Hospital
7777 Forest Lane
Building D, Suite 200
Dallas, Texas 75230
972-566-7226
PARKING: Valet parking and Self-parking is available free to our patients who will be visiting Medical
City Imaging (our Out Patient Diagnostic Imaging Center). Parking access to Building D is located at
the corner of Park Central and Merit Drive.
Building D valet parking available from 8:00 a.m. to 5:00 p.m.
Visitor Parking is open 24 hours a day at the corner of Forest Lane and Park Central Drive for
Buildings A, B and C. Parking fees are as follows:
Up to 1 hour: $1.00 61 minutes – 2 hours: $2.00 Over 2 hours: $3.00
Valet Parking for visitors is available Monday through Friday for $4.00 per day at Building A and C
from 8:00 a.m. – 6:00 p.m.,
and at Building D from 8:00 a.m. – 5:00 p.m.
Parking Meters are also available on Park Central Drive.