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UCLA PET/CT Request Form

Ahmanson Biological
Imaging Center
Nuclear Medicine
Santa Monica: 1245 - 16th Street, Suite 105, Santa Monica, CA, 90404 - Phone: (310) 319-4970 Fax: (310) 319-4980
Westwood: 200 Medical Plaza, Suite B114, Los Angeles, CA, 90095 - Phone: (310) 794-1005 Fax: (310) 267-0227
1. Patient Information *This question is required.
This question requires a valid date format of MM/DD/YYYY.
calendar
Units
Units
Female: Pregnant?
Diabetic?
2. Purpose of PET/CT
Please specify one *This question is required.
Please select the appropriate procedure
*This question is required.
PET/CT (base of skull to upper thigh) and Diagnostic CT with IV contrast of(Note: Serum Creatinine level within 6 weeks of the scheduled PET/CT scan appointment is required)
This question requires a valid date format of MM/DD/YYYY.
calendar
PET/CT (base of skull to upper thigh) and Diagnostic CT without IV contrast of(CT without IV contrast because of medical contraindication to IV contrast)
3. Requesting Physician Signature *This question is required.
Clear
Signature of
4.
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