PET / CT Scan Referral Form - Guyandamp;#39;s and St Thomasandamp;#39; 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the Referring Consultant section. Ensure that you provide your title (Dr/Mr/Prof/Ms), full name, specialty, and contact details including telephone and fax numbers.
3. Next, complete the Patient Details section. Include the patient's first name, surname, date of birth, gender, hospital information, and NHS number if applicable.
4. In the Funding section, circle the appropriate option (NHS, Private Patient, etc.) and provide any necessary insurance details.
5. Clearly state the Reason for Referral and include any relevant clinical information. Attach copies of recent x-ray or scan reports if available.
6. Indicate any specific medical considerations such as diabetes status or need for sedation by selecting 'YES' or 'NO'.
7. Finally, ensure that all sections are completed accurately before signing and dating the form at the bottom.

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