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Scheduling Forms
(please call to schedule, in addition to faxing form)

PET Physician Request forms (revised 11/15/09)

• Oncologic Body and Brain PET/CT (Inpatient)
• Oncologic Body and Brain PET/CT (Outpatient)*
• Non-tumor Brain PET/CT (Inpatient)
• Non-tumor Brain PET/CT (Outpatient)
• Medicare Registry pre-PET form (required for many tumor types in Medicare patients)
• PET coverage indications for Medicare vs PET Registry (NOPR)

Other Nuclear Medicine Scheduling forms

• Breast Lymphoscintigraphy Scheduling Form (north campus)
    (also see Breast Lymphoscintigraphy Scheduling Instructions )
• I-131 Imaging Scheduling Form* (south campus)
• I-131 Treatment Scheduling Form* (south campus )
• MIBG Scheduling Forms
  • Check interfering medications before ordering
  • I-123 MIBG (adults)
  • I-123 MIBG (pediatric)
  • I-131 MIBG (rarely used)
• Octreotide (Somatostatin) Imaging
• Prostascint Scheduling Form  (north campus)
• Thyroid Scan Scheduling Form
• Epilepsy questionnaire
• Myocardial Perfusion Imaging Scheduling Form
  (and ACCF Appropriateness Criteria)

*Indicated forms can be filled out in Adobe Acrobat, for subsequent printing and faxing. These forms can alternately be printed and data manually entered.

Fax and scheduling desk phone numbers