Nuclear Medicine and Specialised PET Services

• Date of referral
• Patient information:
  • Full name, date of birth, contact details, postal address or contact address (if not the same as usual residence)
  • Allergies (drug/ topical preparation)
  • Aboriginal and Torres Strait Islander status (if applicable)
• Referring practitioner:
  • Full name, address and contact details
  • Provider number and signature
• Patient referral information:
  • Image study requested
  • Detailed reason for referral (e.g. for diagnosis, staging, pre-operative assessment, investigation, selection of therapy, guidance of treatment, assessment of treatment effectiveness, or other)
  • Provision diagnosis
  • Please explain if you consider this referral urgent
  • Relevant information about patient’s condition such as previous medical/ surgical treatment (include systemic and topical medications prescribed for the condition) and any associated medical conditions which may affect the condition or its treatment (e.g. Diabetes)
  • Relevant recent investigations (pathology, radiology, histology etc)
  • Current medications and doses, prescribed and over the counter (Note any recent changes in drug therapy)

• Relevant social and Family history
• Smoking & alcohol history (if applicable)
• South Sea Islander status (if applicable)
• Interpreter requirements (if applicable)

• Patient weight (in large or small patients and in different ages, consideration should be given to adjustment of the administered activity)
• Can the patient lie flat?
• List any red flags, alarm symptoms or warning signs
• Has the patient had a recent NM test?
• Has the patient had recent contrast?
• Is the patient pregnant?
• Breast feeding
• Claustrophobic

• Indicate if any of the following applies to your patient:
  • Diabetic
    • On insulin
    • On metformin
  • Pregnant
  • Breast feeding
  • Claustrophobic
  • Unable to lie flat
  • Weight

• >70 years;
• Hx Renal insufficiency
• On metformin
• Previous reaction to radiological contrast (provide details)

If the answer is “Yes” to any of the above please provide serum creatinine, eGFR and date tested