Park West Imaging :: Patient Forms

PET SCAN INFORMATION SHEET
Name:
Birth Date:
Social Security #:
DOCTORS THAT NEED A REPORT OF THE PET SCAN EXAM:
Primary doctor:
Referring doctor:
Any other doctor:
When is your next doctor appointment?
Do you need to take any films with you today?	Yes No
Have you had any previous exams? (X-Rays, Cat Scans, Ultra Sounds, Mammograms or an MRI)
If so, Where and When?
If your report and films are requested by a doctor not listed above, does Parkwest Imaging have your consent to release this information?	Yes No
*PLEASE LIST THE PERSON OR PERSONS THAT HAVE YOUR PERMISSION TO PICK UP YOUR FILMS AND/OR REPORTS ON YOUR BEHALF.*
Name:
Relationship:
Name:
Relationship:
(YOU WILL NEED TO LET US KNOW IN WRITING IF YOU WISH TO ADD ANYONE OR REMOVE ANYONE FROM THIS LIST.)
PATIENT SIGNATURE:
DATE: