Nuclear Medicine Requisition

Patient Identification
Nuclear Medicine Requisition
G19, Basement of Pavilion G
3755 Cote-St-Catherine Road
Montreal, Quebec, H3T 1E2
Tel: 514-340-8222 ext. 5374
Fax: 514-340-7919
www.jgh.ca/nm
Cardiovascular
 MUGA (LVEF)
 First Pass Study (RVEF)
 L-R Shunt (First Pass)
 R-L Shunt (MAA)
 Exercise Myocardial Perfusion (MIBI)
 Persantine Myocardial Perfusion (MIBI)
 Rest/Rest Thallium (Viability)
Gastrointestinal
 Liver & Spleen Scan
 Hemangioma Scan (Liver)
 HIDA Scan
 Liquid Gastric Emptying
 Gastroesophageal Reflux
 Aspiration Study
 Esophageal Transit
 Lower GI Bleed
 Salivary Gland Scan
 Meckel’s Scan
Endocrine
 Thyroid Uptake & Scan
 I-131 Whole Body Scan (4 mCi)
 Thyrogen Stimulated
 Thyroid Hormone Withdrawal
 Parathyroid Scan
Nuclear Medicine Department Use
Inj. 1: _____________________________
Date & Time: ______________________
Site: _________________
Tech: ________________
Inj. 2: _____________________________
Date & Time: ______________________
Site: _________________
Tech: ________________
Genitourinary
 Renal Scan
 Lasix Renal Scan
 Captopril Renal Scan
Oncology
 Lymphoscintigraphy
 Breast Lesion Localization
 Scintimammography
Inj. 3: _____________________________
Date & Time: ______________________
Site: _________________
Tech: ________________
Lung
 V/Q Lung Scan
 Quantitative Q Scan
Therapy
 I-131 for Thyroid Cancer & WB Scan
Dose _________ mCi
 Thyrogen Stimulated
 Thyroid Hormone Withdrawal
 I-131 for Hyperthyroidism
Dose _________ mCi (optional)
Med. / I-131: ________________________
Date & Time: ______________________
Musculoskeletal
 Bone Scan
 Whole Body
 Site __________________
 Whole Body Joint Scan
 Bone Mineral Density (DPX)
Site: _________________
Tech: ________________
VQ
Vent: _____________ kilo-counts/sec
Perf: _____________ kilo-counts/sec
Blood Pressure
Infection
 Gallium Scan
 Whole Body
 Site __________________
Other
 ___________________________
BP 2: ________________ mmHg
 SPECT
(NB: FDG PET/CT requires a different requisition.)
Is the patient pregnant, breastfeeding or nursing?
BP 1: ________________ mmHg
 Yes  No
Coded: ________________
Weight: ___________ Height: ___________
Clinical Information:
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Staff MD: ____________________________ _________________________ ___________ Date: ___________________
PLEASE PRINT NAME
SIGNATURE
LICENSE #
No requisitions will be accepted without attending staff name; however residents may sign for attending staff.
I-1-60707 (Stores) Rev. November 2014