PETCT Referral Form - InHealth

Page 1 of 2April 2013PETCT Referral Form NHS PRIVATE RESEARCH / OTHERPlease complete all sections of this form.Tel: 0845 600 2953 | Fax: 0845 600 2954 | Email: inl.petctsouth@nhs.netPatient informationNHS Number:PACS Accession Number:Name:Address:Hospital Number:Postcode:Email:Date of birth: Gender: Male FemaleTelephone: (Home) (Work)(Mobile)GP Name:Phone number:Is an interpreter required: Yes No Language:Safety questionsIs there any possibility of the patient Yes No Is the patient breastfeeding? Yes Nobeing pregnant? Is the patient under 18 years old? Yes NoIs the patient diabetic? Yes NoPatient type: Inpatient OutpatientFor inpatients only:Ward:Address:Telephone:Fax:Hospital:Postcode:Email:Request made byName:Signature:Consultant: Specialist Registrar: GMC number:Referring Trust name:Contact point for queries about this referral:N.B. All correspondence and reports will be sent to your Trust PETCT NHS.net account.Special instructionsPre-booked patients for:Date:Site:Booked by (name of MDT contact):Planned follow up Patient:Please book scan for week commencing:Urgent treatment Patient:Result of scan required by:PETCT research trials (where applicable):Is this patient in a research trial? If so, please give the name of the trial and the contact of the Lead Researcher:On:

Page 2 of 2Private patient:Self Pay: Insured: Insurance Company:Policy Number:Claim Authorisation Number:Patient informationNHS Number:Name:Clinical Indication Code (CRIS Code):ICD 10 Code:Clinical information1. Diagnosis and details of primary tumour if known:2. Reason for Scan:Staging Identifying Primary Response to TherapyRecurrent Disease Grading Rising Tumour MarkersInflammation Infection Other - please state3. Treatment detailsPatient currently receiving Radiotherapy/Chemotherapy: Yes NoIf yes please provide details.Completion of Radiotherapy (date):Chemotherapy: Type:Date of last cycle:Date of next cycle:4. Relevant previous imagesReports of relevant prior imaging must be sent with this referral form.Relevant report attached: CT MRI U/S X-Ray PETCT OtherTick if reporter should review images: CT MRI U/S X-Ray PETCT OtherPlease do not send in prior images via the Image Exchange Portal (IEP) transfer. An image request will have to bemade by InHealth in the IEP, before anything is sent.Referral informationDoes this referral meet locally agreed indications for scanning: Yes NoDate of referral:To be completed by ARSAC Certificate holder or delegateName:ARSAC Number:Signature:Date:Scan required:Head and Neck scan Half Body scan (Vertex to Thighs) Eyes to thighs scanOther area (specify):When all sections of this form are complete please forward for ARSAC approval locally - if you do not have localARSAC certificate holder available then send directly to the InHealth PETCT Patient Referral Centre.NHS PETCT Diagnostic Imaging Service | PETCT Patient Referral CentreBeechwood Hall | Kingsmead Road | High Wycombe | HP11 1JLTel: 0845 600 2953 | Fax: 0845 600 2954 | Email: inl.petctsouth@nhs.netNHS PETCT Referral Form April_090413_934 Copyright © 2013 InHealth Limited