Woodburn Nuclear Medicine - Referral Forms

Referral Form

Metro Region PET Center
Woodburn Nuclear Medicine
3289 Woodburn Road, Suite 050, Annandale, VA 22003
Phone: 703-698-5593; Fax: 703-698-5171

Personal Information
Patient's Name:
Date of Birth: Sex: Today's Date:
Home Phone: Work Phone:
Social Security No: Height: Weight:
Reason for Scan/Clinical Question:
Relevant Medical & Surgical History:
Was a CT, MRI, PET scan done on patient in last 12 months? Yes No
If Yes, where? Results:
Referring Physician: Medical Specialty:
Physician's Address:
Physician's Phone: Physician's FAX:
Results: Call Stat Report Phone Report Fax Report (written report will be mailed)

PET Scan

Note: PET/CT Fusion now routinely performed on all "Body" PET scans

Type of PET/CT Fusion Scan Requested:
Body (neck through pelvis with CT anatomical localization) Brain Cardiac-Viability

When ordering for cancer patients, check the appropriate box for designating diagnosis, staging or restaging; Diagnosis Initial Staging Restaging

Diabetes: Yes No Insulin Oral Meds

Recent Cancer Treatment:

CT Scan

Head:
Whole Head Orbital View Posterior Fossa Views
IAC's Temporal Bones Maxillofacial area (Sinuses)

Spine: Cervical Spine Thoracic Lumbar

Body:
Neck Abdomen Chest Pelvis Upper extremity Lower extremity

Contrast:
None With & Without Contrast Only Non-ionic only

Nuclear Medicine Study

Bone:
Whole Body Scan (1) 3-Phase Bone Scan (1); Specify Area:

Cardiac:
Dual Isotope
Thalium Stress Test (2)
Sestamibi Stress Test (2)
        Stress Test Method: Adenosine (2)   Dobutamine (2)    Treadmill (2)
MUGA Rest (3)

CNS: Brain SPECT *

Endocrine:
Thyroid Scan & Update (I-123)(4) I-123 Whole body Scan (3)
Parathyroid Scan (5)

Gastrointestinal:
Hepatobiliary (HIDA) (6) Hepatobiliary with CCK (6) Liver/Spleen *
Hemangioma Study *

Genitourinary:
Renal Function/Mag (3) * Renal Diuretic/Lasix * Captopril Renal Scan (7)
Renal Cortex (DMSA) * Cystogram *

Pulmonary: Lung V/Q Scan * Lung Quantitative Scan *

NOTE: Scans followed by a (*) require no special preparation. For scans followed by a number, please see the corresponding number listed below in "Patient Instructions for Nuclear Medicine Studies."

Bone Density

DEXA-Bone Mineral Density *

NOTE: Scans followed by a (*) require no special preparation.

Patient Instructions for PET Scans

You should fast for at least six hours before your appointment. You may drink water and continue totake any prescribed medications. If you have diabetes, you should discuss your preparation with our staff.

Patient Instructions for Nuclear Medicine Studies

1. Bone Scan - After receiving an injection you will be required to drink one quart of fluid during a 2 to 4 hour period. You will then return for the camera images at a time that will be given to you when you receive the injection.

2. Cardiac Stress Tests - Nothing by mouth for 4 hours prior to study. Wear comfortable clothing and footwear. You will exercise on a treadmill for the first part of the study, and images will be obtained immediately after the exercise. You will then return for more images (no exercise) 3 to 4 hours later. It is very important that no caffeine be consumed 24 hours prior to the test, including certain medications, chocolate, soda, tea and even decaffeinated tea and coffee. Check with your cardiologist to see if your usual medications are to be taken the morning of the test.

3. MUGA Scans - Wear comfortable exercise clothing and footwear. Do not eat a heavy meal prior to the test.

4. Thyroid/Parathyroid Scans - Nothing by mouth 8 hours prior to the test (after midnight for morning scans; after 8 a.m. for afternoon scans). No seafood should be eaten for 3 days prior to the study. Patients must stop taking all thyroid medications and any other medications containing iodine for 2 to 4 weeks prior to the test. this should be coordinated and supervised by your referring physician.

5. Whole Body Scans - No seafood should be eaten for 3 days prior to the scan. A pregnancy test must be done by your referring physician prior to the study and faxed to Metro Region PET Center. For patient having a whole body scan, their TSH reading should be above 35.

6. Hepatobiliary Scans - Nothing by mouth, including water, for 8 hours prior to the scan.

7. Captopril Renal Scans - Certain anti-hypertension medications must be stopped for two days under the supervision and care of your referring physician. One hour before the scan, you will be given Captopril medication orally, and then your blood pressure will be monitored.

Requestor's Name and E-Mail MUST be filled in for the form to be sent

Requestor's Name: E-Mail: