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PET/CT 
IMAGING REQUEST

Appointment Time: Day: Date: Location:

PA
TI

EN
T 

D
ET

AI
LS Name:   Interpreter        Language: DOB:

Address: Patient type:            Medicare eligible       MVA

  Work injury       DVA           Non-Medicare
Gender:     Male       Female   

  Unspecified
Patient election:       Private        Public Telephone No:

UR No:  
(if relevant) 

Outpatient Clinic: 
(if relevant) Medicare No:

TYPE OF PET SCAN REQUEST

CL
IN

IC
AL

 D
ET

AI
LS

Reason for PET scan: 

  18 F-FDG

  Clinical Trial PET

  Other:

  Gallium-68 PSMA

  Gallium-68 DOTATATE
Primary site of disease

Histology Height: cm Weight: kg

Known allergies:

Possibility of pregnancy:    Yes    No Date of LMP: Breastfeeding:    Yes    No

  U/S guided cannulation   MRSA / VRE     Diabetes    Other relevant considerations / alerts: 

REFERRING CLINICIAN

CO
PY

 O
F 

R
EP

O
RT

 T
O Name:   NPH (Not for Public Health System Distribution)

  Do not send reports to My Health RecordName

Address Address: RESULTS

Pager / DECT No   Fax No:
  Medinexus 
  Films / Images

  Hardcopy report to referrer
  Date required:Provider no

Telephone No 
(for any urgent/ unexpected results)

DOCTORS SIGNATURE       Date:

Please bring this request form, your Medicare card and any relevant previous films/results to your appointment.  
There is no out of pocket expense for Medicare eligible patients. 
Your doctor has recommended that you use a South Australia Medical Imaging site for your imaging examination.  
You may take this request to another diagnostic imaging provider however it is important to discuss this with your doctor first.

O
TH

ER
 C

LI
N

IC
AL

 
D

ET
AI

LS

Recent Surgery: Date:

Recent or ongoing Chemotherapy, Radiotherapy or GCSF: Most recent treatment: Date: No of Cycles:

Desired scan date: (not asap) or before:

Previous Imaging: Site:

sahealth.sa.gov.au/sami

A Medicare benefit may be payable for this service (see Medicare Benefit Schedule).
To assist us in determining this please indicate if the following indications apply to this patient:

18F   FDG PET: STAGING / DIAGNOSIS OR 18F   FDG PET: STAGING RESTAGING / SURVEILLANCE

  Solitary Pulmonary Nodule
  Staging of newly diagnosed NSCLC (lung cancer) being considered for radical RT or surgery
  Brain   primary tumour grading / biopsy guidance
  Cervical cancer staging prior to radical RT or combined modality therapy
  Staging of newly diagnosed oesophageal cancer for radical RT or surgery
  Staging of newly diagnosed gastric cancer being considered for surgery
  Staging of newly diagnosed head and neck cancer
  Evaluation of metastatic cervical nodes from an unknown primary tumour
  Staging of newly diagnosed lymphoma
  Metastatic malignant melanoma with potentially resectable disease
  Identification of biopsy site for sarcoma
  Staging of bone or soft tissue sarcoma (excluding GIST)
  Evaluation of locally advanced breast cancer being considered for active therapy
  Epilepsy   pre-surgical localisation of epileptogenic focus where standard  
assessment inconclusive

  Ischaemic heart disease   prior to re-vascularisation surgery and standard viability tests are 
negative or equivocal

  Infection: please specify:
  Inflammation / vasculitis, IgG4 Disease

  Restaging of colorectal carcinoma in patients being considered for resection of limited liver or 
pulmonary metastases

  Restaging of colorectal carcinoma with structural suspicion of recurrence
  Restaging of ovarian cancer
  Further staging of cervical cancer with confirmed local recurrence
  Brain   primary tumour restaging recurrence or radiation necrosis
  Restaging of head and neck cancer
  Evaluation of residual mass after treatment of lymphoma
  Restaging of suspected recurrent or residual lymphoma
  To assess lymphoma response to second line chemotherapy when Stem Cell Tx is considered
  Metastatic malignant melanoma with potentially resectable disease
  Restaging of sarcoma following definitive therapy (excluding GIST)
  Evaluation of suspected recurrent or metastatic breast cancer being considered for active therapy

GALLIUM-68 PET
Gallium-68 Dotatate

  Staging suspected Gastroenteropancreatic tumour (GEPNET)
  Exclusion of Gastroenteropancreatic (GEPNET) metastases

Gallium-68 PSMA
  Staging prostate cancer
  Restaging prostate cancer

OTHER

  Other tumour / indication please specify:

  Other PET scan please specify:

  Research trial: please specify:

(SAMI.2-19.24) 



Patient  
preparation  
and instructions

Please inform our staff 
when booking your 
appointment if you:

Are claustrophobic,  
pregnant or breast feeding, 
have limited mobility or 
have difficult veins for 
injection.

If you are on medication, 
please continue taking it 
unless otherwise advised.

For Nuclear Medicine 
studies not listed, and 
all paediatric patients, 
procedure details will be 
explained by our staff when 
making your appointment.

MYOCARDIAL PERFUSION 
SCAN (MPS)
Most scans require 2 visits, 
up to 5 hours duration in 
total. Please do not have any 
caffeine (e.g. coffee, tea, cola, 
chocolate) for 24 hours prior 
to your appointment and dress 
appropriately for physical 
exercise. Please inform our 
staff when booking if you are 
taking beta blocker medication 
or you are asthmatic.

BONE SCAN
2 visits, 3 4 hours duration.

RENAL SCAN
1 2 hour duration  
(3 hours if GFR requested).

Please come to your scan 
well hydrated.

PARATHYROID SCAN
2 visits, 3 hour duration 
in total.

THYROID SCAN
1 hour duration. Please  
check your medication status 
with our staff at time of 
booking and inform them  
if you have had a CT scan  
in the last 4 weeks.

GASTRIC EMPYTING SCAN
Up to 4 hours duration.  
Please do not have any food 
for 6 hours prior to the test  
and only plain water up to  
2 hours prior to the test.  
Please check your  
medication status with our 
staff at the time of booking.

BILIARY SCAN
1-2 hour duration. Fast for
6 hours. Please hold opioid
medications for 24 hours
prior to the study.

LUNG (V/Q) SCAN
1 hour duration.

GATED BLOOD POOL 
SCAN (GBPS)
1 hour duration.

ALL PET SCANS
General information:

3 hour duration. Please come 
to your appointment well 
hydrated. 1 2 business days 
prior, your appointment and 
preparation will be confirmed 
with you by our staff.

FDG PET SCAN
Please do not have anything  
to eat or drink, except for  
plain water for 6 hours  
prior to your appointment. 
Please refrain from strenuous 
exercise and repetitive 
movement for 24 hours prior  
to your appointment. If you  
are diabetic please inform  
our staff when booking.

BONE DENSITY SCAN
30 minute duration. Please 
wear loose fitting clothing  
with no metal (in pockets  
or fasteners on clothing) 
around the lower abdomen, 
waist or hip.

ALL BREATH TESTS
General information:

Please do not have anything 
to eat and only plain water  
for 9 hours prior to the test.

UREA BREATH TEST
30 minute duration. Eradication 
therapy/antibiotics are to be 
ceased for a minimum of  
4 weeks. Proton pump 
inhibitors are to be ceased for 
minimum 7 days. H

2 receptor 
antagonists are to be ceased 
for a minimum of 9 hours.

TRIOLEIN BREATH TEST
6 hour duration. If you take 
Creon medication please bring 
it with you to the appointment.

XYLOSE BREATH TEST
1 hour duration.

THERAPY
Procedure details will be 
explained by our staff when 
making your appointment.

DIRECTORY OF SERVICES 
SOUTH AUSTRALIA MEDICAL IMAGING

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REGION SITE NAME AND ADDRESS TELEPHONE FAX

CENTRAL Royal Adelaide Hospital Medical Imaging
Level 3C (Ground), 1 Port Road, Adelaide (08) 7074 4020 (08) 7074 6136                  
Royal Adelaide Hospital Nuclear Medicine  
Level 2, Lift E - 1 Port Road, Adelaide 1300 724 319 (08) 7074 6122          

Women s and Children s Hospital Medical Imaging  
Level 2, Rogerson and Queen Victoria Buildings,  
72 King William Rd, North Adelaide

(08) 8161 6055 (08) 8161 6333                      

NORTH Lyell McEwin Hospital Medical Imaging  
120   130 Haydown Rd, Elizabeth Vale (08) 8182 9999 (08) 8182 9998                  
Lyell McEwin Hospital Nuclear Medicine  
120   130 Haydown Rd, Elizabeth Vale (08) 8182 9992 (08) 8282 1395      

SOUTH Flinders Medical Centre Medical Imaging   
Level 2 &amp; Level 3, Flinders Drive, Bedford Park (08) 7117 2555 (08) 8204 6193                          
Repat Health Precinct Medical Imaging  
216 Daws Road, Daw Park (08) 7117 2500 (08) 7117 2525            

WEST The Queen Elizabeth Hospital Medical Imaging 
Ground Floor, Main Building, 28 Woodville Road, Woodville South (08) 8222 6894 (08) 8222 6040                  
QE Specialist Centre 
Unit 2, 35 Woodville Rd, Woodville South (opposite TQEH) (08) 8222 6565 (08) 8222 6585          

The Queen Elizabeth Hospital Nuclear Medicine  
Level 3, Area A, Main Building, 28 Woodville Road, Woodville South (08) 8222 6431 (08) 8222 6038      

COUNTRY Murray Bridge Soldiers  Memorial Hospital  
96 Swanport Road, Murray Bridge (08) 8535 6740 (08) 8535 6741            
Port Pirie Hospital  
The Terrace and Alexander Street, Port Pirie (08) 8638 4519 (08) 8638 4368              
Riverland General Hospital  
10 Maddern Street, Berri (08) 8580 2430 (08) 8580 2440              
Clare Hospital  
47 Farrell Flat Road, Clare (08) 8842 6512 (08) 8842 3541    

Please note hours of operation vary across sites and some services may be available on weekends at selected sites.  
Not all sites offer the full range of examinations for each service and you may be directed to another site when making your booking.

sahealth.sa.gov.au/samiPatient preparation details will be confirmed at the time of making an appointment.


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