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722 West 168th Street • R1 Floor • New York, NY 10032 Phone: 212.342.2899 • Fax: 212.342.3745
David A. Gardner PET Imaging Research Center
COLUMBIA UNIVERSITY COLLEGE OF PHYSICIANS & SURGEONS Morton A. Kreitchman PET Center & David A. Gardner PET Imaging Research Center work in association with Columbia-Presbyterian Eastside Radiology.
Patient’s Name: ___________________________________________________ Social Security Number:________________________ Home Phone: __________________________ Work Phone: ______________________ Cell Phone: _________________________ Date of Birth: ____________________________________ Age: _________ Sex: _____ Height: ___________ Weight: ____________ Pregnant? Yes No First Day of Last Menses: ________________________________________ Breast Feeding? Yes No
Insurance Carrier: ________________________________ Insurance Identification #: _______________________________________ Referring Physician: ________________________________________________ Medical Specialty: ____________________________ Physician’s Address: ____________________________________________________________________________________________ UPIN#: _____________________NPI# _________________License#: ____________________________________________________ Phone Number:_____________________________ Fax: ________________________ E-mail: ________________________________ Type of PET-CT Scan requested:
Initial Staging
■ PET-CT 78815
■ PET-CT 78816
■ PET-CT 78608
■ PET-CT 78814
Type of PET Scan requested:
Initial Staging
■ PET 78812
■ PET 78813
■ PET 78608
■ PET 78811
Diagnostic IV Contrast Enhanced CT scheduled same day as PET or PET-CT:
■ CT from Skull Base to Mid Thigh
■ CT from Head to Mid Thigh (e.g. Melanoma)
70491, 71260, 74160, 72193
70460, 70491, 71260, 74160, 72193
■ CT of the Brain 70460 ■ CT of the Neck 70491 ■ CT of the Chest 71260
■ CT of the Abdomen 74160 ■ CT of the Pelvis 72193
Reason/ICD9 Code for PET Scan: _______________________________________________________________________
____________________________________________________________________________________________________________ Last Treatment Date: Surgery: _________________ Radiation Therapy: _________________ Chemotherapy: _________________
Relevant Medical / Surgical History (e.g., Infection, Medications): ________________________________________________________
____________________________________________________________________________________________________________ Signature of Requesting Physician: ________________________________________________Today’s Date: ____________________
PET or PET-CT Pre-authorization#: ________________________ IV Contrast CT Pre-authorization#:________________________
Appointment Date: ____________________ Patient Columbia MRN: _____________________________________________________ Film requested Yes No
Film or CD (address): _________________________________________________________________ Yes No
_________________________________________________________________________________ Yes No
Fax #:____________________________________ Fax #:____________________________________ For Kreitchman PET center use only
Brain Neck Chest
Abdomen Pelvis
Fellow: _________________ Scheduler: _________________ Previous patient: No Yes PET-CT PET Date: ___________________
Comments: _____________________________________________________________________________________________________ PLEASE TURN OVER FOR ADDITIONAL INFORMATION.
Patient Preparations
1. Within 24 hours prior to your appointment:
E. Avoid wearing clothing and jewelry that contain metal F. Children and pregnant women should not accompany patient to G. Average stay at the facility will be two hours 2. Within 6-12 hours prior to your appointment:
5. Diabetic patients:
A. Insulin dependent patients should not administer insulin within 3. Within 6 hours prior to your appointment:
B. Glucose level must be 200mg/dl or below at time of 4. On the day of your appointment:
6. For claustrophobic & pediatric patients:
A. Take all prescribed medications as directed A. Sedatives may be prescribed by the referring physician. Sedation B. Bring prior CT or MRI films to appointment is strongly recommended for Head & Neck protocol. C. Notify staff of possible pregnancy or breast feedingD. Pre-scan pregnancy blood test may be required Diagnostic IV Contrast Enhanced CT Patient Preparations
1. Allergies:
3. Diabetic patients:
A. Careful assessment for allergies must occur prior to the A. Diabetic patients taking metformin (e.g., Glucophage®, administration of contrast. Iodinated contrast agents have the Glucophage XR®, Avandamet®, Metaglip®, Actoplus Met®, potential to cause allergic-like reactions. Reactions may occur Janumet®, Glucovance®) are at risk for lactic acidosis if immediately or take several hours to present. metformin is taken concurrently with iodinated contrast B. Non-iodinated contrast agents such as barium sulfate suspension or ReadiCat® may contain gums or carrageenan B. Follow up BUN/Creatinine levels should be obtained within 48 components which have the potential to cause latex-allergy hours after administration of iodinated contrast to exclude like symptoms or anaphylactic reactions. In patients with latex BUN/Creatinine elevation prior to resuming metformin. allergies, barium products cannot be administered.
4. Explain common sensations caused by intravenous contrast media:
2. BUN/Creatinine levels must be obtained within 2 weeks prior to
A. Warm, flushed feeling throughout the body administration of iodinated contrast in patients with the following
5. Patients who are nursing/breastfeeding must be instructed to
B. Diabetes with known or suspected renal disease discontinue nursing for 24 hours after receiving contrast.
C. Diabetes on oral hypoglycemics containing metformin 6. No solid food may be consumed for at least six (6) hours prior to the
D. Severe atherosclerotic disease (prior MI, stroke, bypass procedure. Patients should take all of their prescribed medications.
7. Administration of iodinated contrast must not be repeated within a
24-hour period without a physician’s note in the medical record.
F. Sickle cell disease G. Myasthenia Gravis H. History of chemotherapy within 2 months Directions to Morton A. Kreitchman PET
Center and David A. Gardner PET
Imaging Research Center
Our facility is conveniently located at 722 West 168th Street and crossstreet Haven Avenue on the R1 floor. Parking is available at theMilstein Hospital entrance or you may park at the hospital lot on FortWashington Avenue between 164th and 165th Streets. For publictransportation, you can take the A, C, or subway lines or the M2, M3, M4, M5, M100, or BX7 bus lines to 168th street. Handicap Assistance: Please call if handicap assistance is needed.
Columbia University diagnostic imaging services in association with Columbia-Presbyterian Eastside Radiology, Morton A. Kreitchman PETImaging Center, & David A. Gardner PET Imaging Research Center



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