Website: www.kmhlabs.com 905-855-1860 ♦ 1-877-KMH-LABS (564-5227) ♦ Fax: 905-855-1863

PET/CT – Oncology Insured and Registry Requisition

TO BE COMPLETED BY THE REFERRING PHYSICIAN
  1. Please complete form
    and fax to KMH
  2. See page 3 for completion  instructions

*** Complete & submit PART 1-4 as applicable and PART 5 for all requests

Patient Demographics

Surname: First Name: Middle Name:

Sex: M     F     Province: Postal Code: Phone:

OHIP Number: Date of Birth:

PART 1 OHIP INSURED INDICATIONS

Eligibility for PET/CT for Undiagnosed Solitary Pulmonary Nodule (SPN) due to:

1. Failed Fine Needle Aspiration (FNA) or other biopsy attempt 3. SPN inaccessible to FNA

2. Medical condition(s) preclude(s) invasive intervention to establish diagnosis

Eligibility for PET/CT for Non-Small Cell Lung Cancer, Potentially Resectable or Candidate for Curative Combined Therapy

Indicate Pre-PET Stage: Clinical Stage I Clinical Stage II Clinical Stage IIIA Clinical Stage IIIB

Attach CT report and provide images on film or CD       Other information regarding eligibility:

Eligibility for PET/CT for Small Cell Lung Cancer, Potentially Resectable or Candidate for Curative Combined Therapy

Indicate Pre-PET Stage: Clinical Stage I Clinical Stage II Clinical Stage IIIA Clinical Stage IIIB

Attach CT report and provide images on film or CD       Other information regarding eligibility:

Eligibility for PET/CT for Lymphoproliferative Disorders

Post Therapy Lymphomas: Residual Mass > 2 cm, AND Biopsy unable to be performed

Hodgkin’s International Prognostic Index Score (IPI Score) 0 – 7: , OR

Non-Hodgkin’s International Prognostic Index Score (IPI Score) 0 – 5:

Assessment of Response to Treatment (Hodgkin’s Disease Only)

Chemotherapy to date: 2 Cycles completed, OR   3 Cycles completed

Hodgkin’s: Stage IA or Stage IIA           International Prognostic Index Score (IPI Score) 0 – 7:

Eligibility for the PET/CT for the following indication:
 Last two biomarker results
The patient must have:
A. Received primary therapy, AND
B. Recent imaging (CT, US, MR, or I131 scanning)
      that is negative or equivocal, AND
C. Biomarkers that are elevated
possible recurrent thyroid cancer Biomarker: Value 1: Value 2:
possible recurrent colorectal cancer Biomarker: Value 1: Value 2:
possible recurrent germ cell cancer Biomarker: Value 1: Value 2:

Other information regarding eligibility

PART 2 REGISTRY INDICATIONS

Eligibility for PET/CT for Potentially Resectable Esophageal cancer

The patient must be eligible for surgery based upon conventional imaging. Attach CT report and endoscopic ultrasound report.

CT images must be provided to the PET/CT Centre on CD or film.       Purpose Staging

Esophageal Cancer - Clinical Stages:

Eligibility for PET/CT for Potentially Resectable Pancreatic cancer

The patient must be eligible for surgery based upon conventional imaging. Attach CT report.

CT images must be provided to the PET/CT Centre on CD or film.       Purpose Staging

Pancreatic Cancer - Clinical Stages:

Eligibility for PET/CT for Melanoma

Purpose Staging         Evaluation of Isolated Metastasis

(choose 1 option from each column)

Eligibility for PET/CT for Testicular Cancer

Purpose: Treatment response assessment  

Post treatment residual mass    

PET/CT – Oncology Insured and Registry Requisition

TO BE COMPLETED BY THE REFERRING PHYSICIAN

***Complete & submit PARTS 1-4 as applicable and PART 5 for all requests

PART 3   ONTARIO PET/CT ACCESS PROGRAM

Diagnosis: (please include topography, histology,
clinical stage and pathological stage if known)

PET/CT Scan Indications (check all that apply)

Diagnosis Restaging
Staging Treatment planning
Prognostic value Other, (please specify):
Risk stratification/response assessment
Response-adapted therapy
Surveillance/recurrence
If PET/CT scan is positive then
patient management would be…

If PET/CT scan is negative then
patient management would be...

 

Has histology been confirmed? Yes No
If no, reason why histology not confirmed:

How would PET/CT scan influence the clinical management of this patient?
(check all that apply)

Determine whether treatment vs. observation

Determine whether to give curative vs. palliative treatment

Determine whether surgery vs. chemotherapy/radiotherapy/combination

If chemotherapy, determine single vs. combined treatment modality

Determine whether to alter current therapy (continue, add, change dose or type)

Other, (please specify):

What will a PET/CT scan demonstrate that cannot be proven
by other means?

PART 4   ONTARIO CARDIAC FDG PET/CT IMAGING  

IA. FDG PET/CT VIABILITY REQUIREMENTS (complete sections IA, II and III)

LVEF ≤ 40%         STATE EF =         NYHA II III IV

Candidate for revascularization or heart transplant Yes No

If the patient DOES NOT meet the above requirements, they may be eligible for
viability or other FDG PET/CT imaging via SPECIAL ACCESS.

B. SPECIAL ACCESS FDG PET/CT IMAGING (complete sections IB, II, III
plus the SPECIAL ACCESS explanation)

CURRENT DIAGNOSIS: AORTITIS     LVEF≥ 40%     SARCOIDOSIS

SARCOIDOSIS TREATMENT FOLLOW UP OTHER

II. PRIOR CARDIAC IMAGING/TESTING COMPLETED (attach copies)

Stress perfusion Yes No Stress Echo Yes No
Stress MRI Yes No Coronary Angiogram Yes No
Cardiac CT Angiogram Yes No Pulmonary testing Yes No
Thoracic CT Yes No ECHO Yes No
MUGA Yes No MRI Yes No
OTHER

 

III. PERTINENT CLINICAL INFORMATION (please indicate "Yes or No")

Diabetes Yes No LBBB Yes No
MI in last 30 days Yes No CABG Yes No
Previous PCI Yes No Pacemaker Yes No
Renal Dysfunction Yes No AICD Yes No
If yes, latest Cr. (UMOL/L) CRT Yes No

IV. For CARDIAC SARCOID complete the following (check all that apply)

Known Pulmonary/Systemic Sarcoid

Heart Block Yes No

    First Degree   Second Degree   Third Degree   Candidate for pacemaker

ECG Abnormality Yes No   RBBB   LBBB   Other:

Ventricular Arrhythmia     Candidate for ICD

Cardiomyopathy

For SPECIAL ACCESS please provide an explanation of how Cardiac FDG
PET/CT will influence the clinical management of this patient.

If Stress Perfusion not previously done please indicate if it is required Yes No

Special Access Office Use Only        TRACKING NUMBER:

Date of Request: Scheduled Date of PET/CT Scan:

PART 5

For each eligibility criterion, please provide the most recent and relevant imaging report(s) (e.g. CT, MRI, US), and digital images (CD),
and pathology report(s) if applicable.

Relevant Imaging studies included, (indicate type of imaging):

    Biomarker: Value 1: Value 2: Date:

    Biomarker: Value 1: Value 2: Date:

    Biomarker: Value 1: Value 2: Date:

    Biomarker: Value 1: Value 2: Date:

    Biomarker: Value 1: Value 2: Date:

    Biomarker: Value 1: Value 2: Date:

Additional Comments:

Referring Physician Information:

Surname: First Name: Middle Name:

CPSO: Phone: ext: Fax:

Email:
(Optional)

Physician Signature: _______________________________________________________________ Date:

Fax Instructions: Please fax to 905-855-1863 the completed request form (PARTS 1- 4 as applicable and PART 5),
along with the required previous imaging results.

PET/CT – Oncology Insured and Registry Requisition

KMH would appreciate your assistance in following the procedures outlined below in order to minimize delays and
expedite scheduling on PET/CT appointments.
  1. Please provide accurate and current patient demographic information, especially day and home telephone numbers so we may contact the patient to book their appointment.
  2. Reason for performing the test, relevant clinical information, as well as reports from relevant previous diagnostic tests and surgical interventions must accompany the requisition to ensure the correct protocol is assigned by our Nuclear Medicine Physician. Please ensure the CD for the appropriate imaging study is sent to KMH in order to fulfill OHIP eligibility criteria.
  3. To ensure a diagnostic examination, the patient needs to fast for 6 hours prior to their appointment. Drinking water is allowed and encouraged within fasting period. For afternoon appointments, patients are permitted to have a light breakfast before the 6-hour fast.

For patients with Diabetes:

  1. Hyperglycemia (blood glucose level > 10-11 mmol/L) can significantly interfere with tumour imaging and lead to a suboptimal study. Reasonable glycemic control should be achieved before referring diabetic patients for this test.
  2. Oral  hypoglycemic medication (diabetic pills) should be discontinued the day of the test. Consideration will be made to schedule patients on oral hypoglycemic medication in the morning.
  3. Patients can continue their routine administration of insulin with a light breakfast. (Referring physician may advise patients taking long acting insulin separately from their short acting insulin to only take short acting insulin if appropriate). Consideration will be made to schedule patients on insulin in the early afternoon.

PATIENT INSTRUCTIONS

Please follow the instructions below for the best test results:

  1. Do not eat or drink anything except water 6 hours prior to your appointment.
    No chewing gum, candies and mints allowed the day of the test.
    The test will last approximately 2 hours.
  2. Drink 2-4 glasses of water before your appointment time.
  3. Wear warm, loose, comfortable clothing, preferably without metal zippers or buttons on the day of your test.
  4. Bring a list of all prescription medication you are taking currently.
  5. You may take all your medications (EXCEPT diabetic medications) with water on the day of the test.
  6. If you are diabetic, please follow specific instructions given to you by your referring physician.
  7. If you are claustrophobic, we may give you a sedative. Please arrange for transportation home.


KMH Cardiology & Diagnostic Centres
2075 Hadwen Road, Mississauga, ON L5K 2L3