PRP - Inpatient PET Booking Request
43 William St Gosford
Patient Phone
Select PET/CT Imaging Site
*
Please Select
Gosford William Street
Practice to attend
Patient Name
*
Title (Mr,Mrs)
First Name
Surname
Gender
*
Male
Female
Other
Patient Height
*
Centirmetres
Patient Weight
*
Kilograms
Date of Birth
*
/
Day
/
Month
Year
Hospital
*
Please Select
Gosford District Hospital
Wyong District Hospital
Berkeley Vale Private Hospital
Brisbane Waters Private Hospital
North Gosford Private Hospital
Requesting Hospital
Ward (Wyong)
Please Select
S1
S2
M1
M2
M3
M4
REHAB
IMAGING
Requesting Hospital
Ward (Brisbane Waters)
Please Select
SWITCHBOARD
SURGICAL
IMAGING
Requesting Hospital
Ward (North Gosford)
Please Select
SURGICAL
3 WEST
SWITCHBOARD
Requesting Hospital
Ward (Gosford)
Please Select
C4 Neurology
C5 Gen Med Geri
E4 Transition
G3 Surgical
G4 Orthopaedics
G5 Ortho Vascular
H3 MAU
J3 UTP GOS
J5 Surge
J8 Cardiology
J9 Renal Endocrin
K1 Geriatrics
K2 Geriatrics
K4 Surgical
K6 Cancer
K8 Medical Oncolog
K9 Resp Gastro
MDU Surge GOS
Ward Name
Financial Class
*
Public
Private
Health Fund
Please Select
Healthfund Not In List
ACA: ACA Health Benefits Fund
AHM: Australian Health Management Group
AMA: The Doctors' Health Fund Limited
AUH: Australian Unity Health Limited
BUD: Budget Direct Health Insurance
BUP: BUPA Australia
CBC: CBHS Corporate Health Pty Ltd
CBH: CBH Health Fund Ltd
CDH: CDH Benefits Fund Limited
CHF: Credicare Health Fund Limited
DHF: Defence Health
ESH: Emergency Services Health
FAI: Grand United Corporate Health Limit
GMF Health
GMH: Frank Health Insurance
HBF: Hospital Benefits Fund of WA
HCF: HCF of Australia Limited
HCI: Health Care Insurance Limited
HEA: Health.com.au
HIF: Health Insurance Fund of WA
LHM: Lysaght Peoplecare
LHS: Latrobe Health Services
MDH: Mildura District Hospital Fund Limited
MPL: Medibank Private
MYO: MO Health
NHB: Navy Health Limited
NIB: NIB Health Funds Limited
NMW: Nurses & Midwives Health Fund
OMF: Onemedifund
PHF: Phoenix Health Fund Ltd
POL: SA Police Employees Health Fund Inc
QCH: Queensland Country Health Limited
QTU: Queensland Teacher's Union Health Fund
RBH: Reserve Bank Health Society Ltd
RTH: Railway and Transport Health Fund
SLM: St. Luke's Health
SPS: Health Partners
TFH: Teachers Federation Health Limited
TFS: Transport Health
WFD: Westfund Ltd
Member Number
Mode of transport to PRP
*
Please Select
Patient transport
Health Uber
Private/family member
Current Mobility Status
*
Please Select
Independent - Walks without assistance or aids
Independent with Aid - Uses stick/frame/crutches
Requires Assistance (1 person) - Needs help to walk or transfer
Requires Assistance (2+ people) - Needs 2 or more people
Wheelchair - Uses wheelchair (self or assisted)
Bedbound / Non-Mobile - Requires stretcher or full assistance
Communication Ability
*
Please Select
Independent - Communicates clearly without difficulty
Hearing Impairment - May need louder voice or hearing aid
Speech Difficulty - Has trouble speaking clearly
Language Barrier - Requires interpreter or limited English
Cognitive Impairment - Confused, dementia, or reduced understanding
Non-Verbal - Unable to speak, uses gestures or aids
Unresponsive - No meaningful communication
Infection Status
*
Please Select
No Known Infection
Active Infection (suspected or confirmed)
Recent Infection (within last 2 weeks)
On Antibiotics / Treatment for Infection
Chronic Infection / Colonisation (e.g. MRSA carrier)
Infection Site
Patient Email
Please complete so patient receives a copy of the eReferral
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
Clinical History
*
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 Dependent
Yes
No
Recent Surgery
Yes (Within last 8 Weeks)
No
Surgery Date
/
Day
/
Month
Year
Date of surgery or biopsy
Site of Surgery
(within last 8 weeks)
Recent Biopsy
Yes (within last 4 weeks)
No
Biopsy Date
-
Month
-
Day
Year
Date
Site of Biopsy
Chemotherapy
Yes
No
Last Treatment
/
Day
/
Month
Year
Last Dose
Next Treatment
/
Day
/
Month
Year
Next Dose
Immunotherapy
Yes
No
Last Treatment
/
Day
/
Month
Year
Date
Next Treatment
/
Day
/
Month
Year
Date
Radiotherapy
Yes
No
Site of Treatment
Site of treatment
Last Dose
/
Day
/
Month
Year
Date
Senior Medical Officer
*
First Name
Surname
Provider Number
*
Main Contact for Booking
*
First Name
Last Name
Preferred contact phone number
*
Format: 0000000000.
Email
(To receive copy of this booking request)
Additional Comments
Submit Request
Clear All Questions
PRP - PET/CT Services
Comprehensive PET and Radiology
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