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    Shaukat Khanum Memorial Cancer Hospital and Research Center Lahore PET /CT Scan Request Form MR NO Patient Information

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    ctsamontessori
    This document is a PET/CT scan request form for Shaukat Khanum Memorial Cancer Hospital and Research Center in Lahore, Pakistan. It contains information about the patient, Safeer Ahmed Qureshi, including his name, date of birth, weight, phone numbers, and address. It also includes details about the referring physician, Dr. X, their specialty, hospital, address, and phone numbers. Finally, it lists the types of cancers for which PET/CT examinations are commonly requested, including breast cancer, lymphoma, head and neck cancer, colorectal cancer, lung cancer, gynecological cancers, and others.

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    Shaukat Khanum Memorial Cancer Hospital and Research Center Lahore PET /CT Scan Request Form MR NO Patient Information

    Uploaded by

    ctsamontessori
    142 views1 page
    This document is a PET/CT scan request form for Shaukat Khanum Memorial Cancer Hospital and Research Center in Lahore, Pakistan. It contains information about the patient, Safeer Ahmed Qureshi, including his name, date of birth, weight, phone numbers, and address. It also includes details about the referring physician, Dr. X, their specialty, hospital, address, and phone numbers. Finally, it lists the types of cancers for which PET/CT examinations are commonly requested, including breast cancer, lymphoma, head and neck cancer, colorectal cancer, lung cancer, gynecological cancers, and others.

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    Original Title

    PET form 1

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    This document is a PET/CT scan request form for Shaukat Khanum Memorial Cancer Hospital and Research Center in Lahore, Pakistan. It contains information about the patient, Safeer Ahmed Qureshi, including his name, date of birth, weight, phone numbers, and address. It also includes details about the referring physician, Dr. X, their specialty, hospital, address, and phone numbers. Finally, it lists the types of cancers for which PET/CT examinations are commonly requested, including breast cancer, lymphoma, head and neck cancer, colorectal cancer, lung cancer, gynecological cancers, and others.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    142 views1 page

    Shaukat Khanum Memorial Cancer Hospital and Research Center Lahore PET /CT Scan Request Form MR NO Patient Information

    Uploaded by

    ctsamontessori
    This document is a PET/CT scan request form for Shaukat Khanum Memorial Cancer Hospital and Research Center in Lahore, Pakistan. It contains information about the patient, Safeer Ahmed Qureshi, including his name, date of birth, weight, phone numbers, and address. It also includes details about the referring physician, Dr. X, their specialty, hospital, address, and phone numbers. Finally, it lists the types of cancers for which PET/CT examinations are commonly requested, including breast cancer, lymphoma, head and neck cancer, colorectal cancer, lung cancer, gynecological cancers, and others.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 1

    SHAUKAT KHANUM MEMORIAL CANCER HOSPITAL AND RESEARCH

    CENTER LAHORE
    PET /CT Scan Request Form

    MR NO

    Patient Information
    PATIENT NAME:_SAFEER AHMED QURESHI__TODAYS DATE 13th Dec, 2014
    DATE OF BIRTH:____________________________ WEIGHT/HEIGHT:________________________
    HOME PH:__________________________CELL PH:_________________________________________
    ADDRESS:_____________________________________________________________________________

    Referring Physician/ Consultant

    Dr./ Prof: _______________________________________________________________


    Speciality:_______________________________________________________________
    Hospital:_________________________________________________________________
    Address:_________________________________________________________________
    Work PH:_____________________________Cell PH:____________________________
    Signature:_____________

    Date: __________________

    PET/CT EXAMINATION REQUESTED- Check appropriate box below:


    Breast Cancer:
    Staging
    Axillary Lymphadenopathy
    Restaging
    Response
    Lymphoma:
    Diagnosis
    Staging
    Restaging

    Esophageal Cancer:
    Diagnosis
    Staging
    Restaging
    Solitary Pulmonary Nodule:
    Distinguish Malignant Vs Benign
    Thyroid Cancer:
    Negative Iodine scan / Rising markers

    Head and neck Cancer:


    (Excluding CNS)
    Diagnosis
    Restaging
    Staging

    Colorectal Cancer:
    Staging
    Restaging

    NSC Lung Cancer:


    Radiation Therapy Planning
    Recurrence
    Staging Biopsy Planning

    Gynecological Cancers:
    Recurrence of Ovarian Primary
    Restaging of Cervical Primary
    Serological Relapse

    Testicular Cancer
    Brain tumors
    Pancreatic Cancer

    GIST
    Liver Cancer
    Melanoma

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