PET Order Form - Fox Chase Cancer Center - fccc 2026

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Click ‘Get Form’ to open the PET Order Form in our editor.
Begin by entering the Patient Name and MR # at the top of the form. These fields are essential for identifying the patient.
In the 'EXAM REQUESTED' section, check one option that best describes the type of PET/CT scan needed.
Next, indicate the purpose of the scan in the 'PET/CT IS BEING REQUESTED TO' section by checking one box.
Fill out the 'DIAGNOSIS' section by selecting one diagnosis from the provided options. Ensure accuracy as this is crucial for medical necessity.
Complete any additional information required, such as pertinent x-ray details and specific areas of interest.
Finally, have the physician sign and date at the bottom of the form to attest to its accuracy before submission.

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