Imaging putrajaya hpjnuk 001 form 2025

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The document is a PET/CT Imaging Request Form from Hospital Putrajaya, designed to collect essential patient information and medical history for scheduling a PET/CT scan. It requires detailed completion of various fields including patient demographics, clinical diagnosis, relevant medical history, treatment details, and management plans. The form emphasizes that it must be fully filled out for the scan to be booked and provides contact information for confirmation.

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Click ‘Get Form’ to open the imaging putrajaya hpjnuk 001 form in the editor.
Begin by filling in the patient’s personal details, including their name, I/C number, date of birth, gender, ethnic group, age, contact number, and address. Ensure all fields are completed accurately.
In the relevant medical history section, indicate any conditions such as diabetes or claustrophobia by ticking the appropriate checkboxes. If information is unavailable, mark with a dash (-).
Provide clinical diagnosis and primary site of disease. Clearly state the reason for the PET/CT study and include any relevant findings from clinical examinations or previous imaging.
Complete the clinical indication section by selecting applicable options for staging or restaging. Fill in additional details as required.
Finally, ensure that the referring consultant's details are filled out correctly along with their signature and contact information before submitting.

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