PRP - PET / CT eReferral
Comprehensive PET & Radiology
Select PET/CT Imaging Site
*
Please Select
Westmead
Gosford William Street
Orange
Bella Vista
Blacktown - Panorama Pde
Shellharbour
East Maitland
Practice to attend
Patient Name
*
First Name
Surname
Date of Birth
*
/
Day
/
Month
Year
Gender
*
Male
Female
Other
Patient Phone
*
Patient Email
Please complete so patient receives a copy of the eReferral
Clinical History
*
PET Imaging Request
*
FDG PET
PSMA PET
DOTATATE PET
Other (e.g. NaF, FET, Amyloid)
Other Imaging Request
Diagnostic CT
Nuclear Medicine
Other (MRI, US, Xray etc.)
Diagnostic CT Request
*
Brain
Neck
Chest
Abdomen
Pelvis
Wholebody
Non-Contrast
Other Region
Nuclear Medicine Request
*
Bone Scan
VQ Scan
Gated Heart Pool Scan
Other Study
PET Indications
*
Brain
Lymphoma
Breast Cancer
Melanoma
Gastrointestinal Tract
Neuroendocrine
Gynaecological
Prostate
Head & Neck
Rare and Uncommon Cancers
Lung
Sarcoma
Non Rebatable
Other (PUO, Vasculitis, Sarcoid etc.)
Brain FDG PET
*
61538 Brain Tumour (Residual/Recurrent)
61559 Refractory Epilepsy
61560 Alzheimer's Disease
Breast Cancer FDG PET
*
61524 Locally Advanced (Staging)
61525 Suspected Recurrent/Mets
GIT FDG PET
*
61577 Oesophageal / GEJ Ca (Staging)
61541 Colorectal Ca (Residual/Recurrent/Mets)
Gynae FDG PET
*
61565 Ovarian Ca (Residual/Recurrent/Mets)
61571 Uterine Cervix Ca (Staging)
61575 Uterine Cervix Ca (Recurrent)
Head & Neck FDG PET
*
61598 H&N Ca (Staging/Recurrent)
61604 H&N Ca (Residual)
61610 Cervical Node SCC (Unknown Primary)
Lung FDG PET
*
61523 Solitary Pulmonary Nodule
61529 NSCLC (Staging)
Lymphoma FDG PET
*
61620 Staging
61622 First Line Response
61628 Recurrence
61632 Second Line Response
Melanoma FDG PET
*
61553 Suspected Mets/Recurrent
Rare and Uncommon Cancer FDG PET
*
61612 (Once per cancer diagnosis)
61614 (Subsequent)
Sarcoma FDG PET
*
61640 Staging
61646 Suspected Residual/Recurrent
FDG Neuroendocrine
*
Non Rebatable
DOTATATE Neuroendocrine
*
61647 GEP NET (Suspected/Mets)
Non Rebatable
FDG Prostate Ca
*
Non Rebatable
PSMA Prostate Ca
*
61563 Staging
61564 Recurrent
61528 Assessment for Lutetium therapy
Non Rebatable
Current PSA
Previous PET
Yes
No
/
Day
/
Month
Year
Date of previous PET
Location of Previous PET
If Known
Previous CT
Yes
No
/
Day
/
Month
Year
Date of previous CT
Location of Previous CT
If Known
eGFR
For patients > 55 or renal insufficiency with Diagnostic CT scan
/
Day
/
Month
Year
Date eGFR taken
Creatinine
For patients > 55 or renal insufficiency with Diagnostic CT scan
/
Day
/
Month
Year
Date Creatinine taken
Primary Site of Disease
Histopathology
Diabetic
Yes
No
Insulin
Yes
No
Surgery or Biopsy Sites
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Day
/
Month
Year
Date of surgery or biopsy
Chemotherapy
Yes
No
/
Day
/
Month
Year
Last Dose
/
Day
/
Month
Year
Next Dose
Immunotherapy
Yes
No
/
Day
/
Month
Year
Last Dose
/
Day
/
Month
Year
Next Dose
Radiotherapy
Yes
No
Site of treatment
/
Day
/
Month
Year
Last Dose
Referring Practitioner
*
First Name
Surname
Provider Number
*
Referrer Email
*
Additional Report to Dr
URGENT
Results required by
Date
Appointment Date
/
Day
/
Month
Year
Choose a date if imaging is required on specific date
Submit eReferral
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PRP - PET/CT Services
Comprehensive PET and Radiology
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