Get Ga68-psma Pet/ct Request Form 2020-2026

Completing the Ga68-PSMA PET/CT request form online is a straightforward process that ensures your imaging request is processed efficiently. This guide will provide step-by-step instructions to help you navigate each section of the form, ensuring accurate and complete submissions.

Follow the steps to complete your request form online.

1. Press the ‘Get Form’ button to retrieve the form and open it in the designated editor.
2. Begin by entering the patient's name and address in the provided fields at the top of the form.
3. Fill in the patient's date of birth and contact number under the 'Patient Label' section.
4. Specify the appointment date and time for the imaging service.
5. Indicate the examination requested by selecting 'Ga68 - PSMA scan (with low dose CT for anatomical localisation)' and whether a separate diagnostic CT is required.
6. Provide the region for the examination if a separate diagnostic CT is needed. Also, enter the most recent creatinine or eGFR level along with the date.
7. In the clinical details section, state the reason for the scan by checking the appropriate options such as diagnosis, staging, or therapeutic monitoring.
8. Include their clinical staging information, PSA level, Gleason score/tumor grade, TRUS biopsy date, and previous surgeries if applicable.
9. Document any ongoing or previous treatments, such as radiotherapy, brachytherapy, or hormone therapy, with relevant dates.
10. Add any additional clinical notes regarding previous malignancies or conditions that might be relevant for the imaging.
11. Choose the pre-PET Ga68 - PSMA management plan from the options provided.
12. In the previous imaging section, check any relevant imaging studies, such as CT, MRI, bone scans, or prior PET/CTs, along with their dates and locations.
13. Complete the requesting consultant section with their provider number, name, specialty, address, and contact details.
14. Ensure the consultant’s signature and date are added at the bottom of the form.
15. Finally, review all entries for accuracy before saving changes, downloading, printing, or sharing the form as required.

Complete your Ga68-PSMA PET/CT request form online today to ensure a timely imaging process.