Schedule An Appointment (PET/CT or CT)

Patient's Name
Home Phone	Work Phone	Cell Phone
Weight	Height	Sex
Date of Birth	Pref. Appointment Date *	Email

* A scheduling representative will call you back to confirm your requested date and time

Diagnosis/Symptoms

PET/CT or CT

PET/CT

Scan CPT Code:

Patient History

(The following questions must be answered.)

Referring Doctor	Phone	Fax

Reports

Films

Call Report

Fax Typed Report

Fax Preliminary Report

Patient to Wait for Film

Send All Films Routine

Send Films Only If Positive

No Film Copies

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