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: .