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 Angiography 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 Surgery D/T ______ Osteomyelitis Mark location with X on image: Other: ______Denatured RBC Study (Accessory Spleen) Gallium Scan Miscellaneous: Dacryoscintigraphy Renal: Renogram Red Cell Mass Lasix Renogram Salivary Scan ACE Inhibitor Renogram Other (indicate): Cortical Scan (DMSA) GFR (DTPA) For Nuclear Medicine Use Only: