NUCLEAR MEDICINE REQUISITION  University Hospital (UH) Fax: 519-663-3860 Tel: 519-685-8300 ext. 37080  Victoria Hospital (VH) Fax: 519-667-6734 Tel: 519 685-8300 ext. 56274  St. Joseph’s Hospital (SJH) Fax: 519-646-6135 Tel: 519-646-6000 ext. 64137 1. PATIENT INFORMATION (attach label or complete): 2. INSURANCE/ BILLING Last name: ______Health card number: ______First Name: ______Middle Initial: ______Version Code: ______Gender: ______Date of birth (YYYY/MM/DD): ______Address: ______WSIB #: ______City: ______Postal Code: ______Accident date: ______Home Phone: ______CRIC #______Alternate Phone: ______Other: ______3. REFERRED BY (please print): 4. CLINICAL INDICATION: Name: ______OHIP Billing #:______Tel.: ______Fax #: ______CC Physician: ______

Date: ______Height______cm Weight______kg Signature: ______Pregnancy/Breastfeeding: Yes  5. IMAGING & FUNCTIONAL STUDIES REQUESTED Brain: Biliary: Cardiac:  Cerebral Blood Flow (Dementia)  HIDA (Cholecystitis)  Myocardial Perfusion Stress Test**  CSF Leak  HIDA (Post Cholecystectomy)  Coronary Calcium Score  CSF Circulation (NPH)  Biliary Leak  Coronary CT  CSF Shunt  Biliary Atresia **Clinic note must be included**  Wall Motion & Ejection Fraction (MUGA) Endocrine: Pulmonary:  Parathyroid Scan  Myocardial Viability (Thallium)  V/Q (Pulmonary Embolism)  Thyroid Uptake + Scan  Cardiac Shunt Analysis  V/Q (Pulmonary Hypertension)  Thyroid Metastatic Survey  Cardiac Amyloid Study  Quantitative Lung Study  Octreotide GI (Non-Biliary):   Aspiration Study MIBG  Gastric Emptying Skeletal: Therapy: Choose :  Solid  Liquid  Bone Scan  Thyroid Consult  C14 Breath Test (H. Pylori)  Bone Mineral Density  Neuroendocrine Consult  Esophageal Motility Choose: Lymphatic:  hip/spine total-body  IVA GI Bleed Localization  Lymphangiogram  Meckels Scan Infection/ Inflammation  Liver/ Spleen Scan  Sentinel Node (mark lesion below)  White Cell Scan  RBC Liver D/T ______ Osteomyelitis  Mark location with X on image:  Other: ______Denatured RBC Study (Accessory Spleen)  Miscellaneous:  Dacryoscintigraphy Renal:   Renogram Red Cell Mass  Lasix Renogram  Salivary Scan  ACE Inhibitor Renogram  Other (indicate):  Cortical Scan (DMSA)  GFR (DTPA) For Use Only: