Fillable Southend University Hospital Trust PET-CT Patient Request Form (Alliance Medical UK)

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Southend University Hospital Trust PET-CT Patient Request Form (Alliance Medical UK)

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The Southend University Hospital Trust PET-CT Patient Request Form (Alliance Medical UK) form is 2 pages long and contains:

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File type: PDF

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Southend University Hospital Trust
PET-CT Patient Request Form
PATIENT DETAILS
HOSPITAL NO: NHS NO:
Title: First name: Surname:
Accession No:
Address:
Postcode: Inpatient Outpatient
Email:
Tel no: Mobile:
Date of Birth: Next of Kin:
CLINICAL INDICATIONS
Reason for referral: (including any surgery, current medication and
correlative imaging):
Please complete all the sections on
this page. Failure to do so may delay
appointment being made.
Please refer to page
2 for the
contraindications to PET-CT
Patient arrival: Trolley Wheelchair Walking
Funding: NHS Self Funded Insured
Research patient: Commercial Non-commercial
REC Trial No:
Trial name:
Patient’s insurance company:
Membership number:
Pre-authorisation number (if known):
Is an interpreter required? Yes No
Is transport required? Yes No
2 week wait? Yes No
62 day target patient? Yes No
Last diagnostic PET-CT: Date: Body area:
Last diagnostic CT: Date: Body area:
Last diagnostic MRI: Date: Body area:
PLEASE ENSURE YOU SEND A COPY OF THE LATEST CT/MRI REPORTS
WITH THE REQUEST FORM
SAFETY CHECK
Could the patient be pregnant? Yes No
Is the patient breast feeding? Yes No
Is the patient claustrophobic? Yes No
Does the patient have mobility issues? Yes No
Is the patient part of a trial? Yes No
If yes, please specify:
Approximate Weight:
IR(ME)R2017 regulations require this form to be signed by the referring
Consultant:
GMC Number:
Email:
Print Name: Date:
Hospital:
Address:
Tel:
Consultant Signature:
Is the patient known to carry a high risk infection ? Yes No
If yes, please specify:
Does the patient have any known allergies? Yes No
If yes, please specify:
Is the patient on steroids? Yes No
Does the patient suffer from diabetes? Yes No
Is the diabetes controlled by:
Diet Insulin Tablet
Does the patient suffer from incontinence? Yes No
REFERRING CLINICIAN DETAILS
G.P. Details: Title: Surname:
Surgery address:
Has the patient had any surgery in the last six weeks?
If yes, please list procedure and anatomical site:
Chemotherapy Radiotherapy
Type:
Cycle length:
Date of last treatment:
Date of next treatment:
MDT date:
Breach date:
Requested date for scan:
XX / XX / XXXX
On completion please email to: southend.pet@nhs.net
AM000339 Sept 2019
MEDICAL HISTORY
SPECIFIC CLINICAL CONTRAINDICATIONS TO PET-CT INCLUDE: Pregnancy or suspected pregnancy
Clinical contraindications rendering the patient medically unfit to undergo the scan include:
Chest drains in situ, Influenza, Chickenpox (Varicella Zoster Virus), Measles (Rubella), Mumps, Clostridium Difficile (may only be scanned at static
centres), Whooping cough (Bordetella pertussis), Active Shingles (Herpes Zoster), Diphtheria (Corynebacterium diphtheriae)
Additional physical and technical contraindications to PET-CT include:
Inability to cooperate with the scan process - For instance, inability to lie relatively still for 1-2 hours and to lie supine for 30-60 minutes
Blood Glucose Level - If the patient’s blood glucose level is outside the ARSAC certificate holder’s agreed limits. In patients with diabetes this must be
adequately controlled prior to attendance for the PET-CT scan. Uncontrolled blood glucose levels may result in sub-optimal or undiagnostic image
quality and therefore in these circumstances the patient’s appointment may be cancelled and re-scheduled for an alternative date when
diabetic control has been established
Chemotherapy/Radiotherapy - If the patient’s appointment date is outside the ARSAC certificate holders agreed time limits
Patient body habitus above scanner dimensions - Scanner Bore Diameter 70cm (distance from scanner bed to roof of scanner approximately 50cm).
If it is uncertain if a patient’s body habitus will prevent us from proceeding with the scan the patient may be invited to attend the scanner prior to their
appointment date to undergo a trial run through the scanner gantry
CLINICAL INDICATION CODING (please tick one box from each table):
Lung Staging JA
Oesophagus Re-staging JB
Colorectal Recurrence JC
Lymphoma Residual Mass JD
Head & Neck
(includes H&N unknown primary) Please state: Follow Up (response to therapy) JE
Melanoma Characterisation JF
Unknown Primary
(excludes H&N unknown primary) Pre-resection Metastases JG
Upper GI
(includes Stomach, Small Bowel, Liver, Pancreas) Please state: Find Unknown Primary JH
Sarcoma Elevated Tumour Markers JI
Breast Paraneoplastic Syndrome JJ
Urological
(includes Renal, Adrenal, Bladder, Prostate, Testicle) Please state: Other Oncology JK
Gynaecological
(includes Ovary, Uterus, Cervix) Please state: Non-Oncology: Neurology JL
Brain & Spinal Cord Please state: Non-Oncology: Cardiac JM
Oncology: Other Please state: Non-Oncology: Other JN
Non-Oncology: Neurology
Non-Oncology: Cardiac
Non-Oncology: Other
(includes vasculitis, infection imaging) Please state:
Patient Name
Protocol required:
Date of Birth
Vertex to toes PET-CT
Base of skull to proximal third of femur PET-CT
Lung Apices to proximal third of femur PET-CT
Symphysis pubis to toes PET-CT
Vertex to proximal third of femur PET-CT
Vertex to Lung Apices PET-CT
Brain PET-CT
Other (please specify)
Prostate - Dynamic PET-CT
Other - Dynamic PET-CT
Clinical authorisation by ARSAC certificate holder or delegate:
Print Name:
Signature:
Date:
ARSAC PROCESS - ARSAC Certificate Holder or Delegate to complete
ARSAC Authorisation (please indicate) Pre-referral to PMC Under delegation
Tracer required:
FDG
Amyloid
NaF
FEC (choline)
Other (please state)
Can patient be scanned in Radiotherapy Planning Position? Yes No
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Southend University Hospital Trust PET-CT Patient Request Form (Alliance Medical UK)

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Completed 27 March 2021

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