PET-CT / PSMA-PET Coordination Program: Intake Form

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We’re here to take care of the details and help you get the answers you need, as quickly and smoothly as possible.

To ensure we arrange the most appropriate scan for your situation, we’ve prepared a few brief questions. Please answer them as best you can.

If you’d prefer to speak with someone directly at any point, our medical office team is here for you. Just call 1-778-999-5463 ext. 0. We’re happy to help.
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We Value Your Privacy

At CTOAM, your privacy is one of our highest priorities. We understand the sensitivity of the personal and health-related information you share with us, and we are committed to protecting it with the utmost care and integrity.

All information collected through our forms and services is handled in strict accordance with British Columbia’s Personal Information Protection Act (PIPA). We use secure, encrypted systems to store and manage data, and we limit access to our privacy-compliant clinical team members.

Your information will never be shared without your explicit consent and will only be used for the purposes clearly outlined in our communications.

You can trust that your data is safe, confidential, and treated with the same respect we offer in every aspect of our care.
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What is the reason you want to get a PET-CT scan?* This field is required.Please select the option that applies to you most.
I wonder if I have cancer and want to know for sure.
I have been diagnosed with cancer and want to confirm the diagnosis is correct.
I want to gain more information about the staging of my cancer, location, level of aggression, and treatment options.
I am currently on treatment and want to monitor how well the treatment is working.
I have been told my cancer is gone and want to confirm that's really true.
I am currently in remission and want to check for recurrence.
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Step 1
Complete this short form. Your answers will help us understand your imaging needs so we can connect you with the most appropriate program and location. When you're done, just click Submit.

Step 2
Within 24 to 48 business hours (Monday to Friday), a member of our care team will call you for a brief consultation. This helps us better understand how we can support you.

Step 3
We’ll identify the closest scan clinics that fit your needs and provide you with a shortlist, including appointment options and associated fees – so you can choose what works best for you.

Step 4
Once you've selected a clinic, we’ll take care of the coordination. We'll schedule your appointment and ensure the scan results are sent to our team within 48 hours.

Step 5
The day before your scan, we’ll give you a quick call to confirm the details, answer any questions, and make sure you feel fully prepared.

Step 6
After your scan, we’ll call you within 48 hours (Monday to Friday, 7:00 a.m. to 5:00 p.m. PT) to walk through your results and discuss any recommended next steps.

Please go ahead and complete the intake form to get started.

We’re here to support you every step of the way.
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Your Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
Confirm Email
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Phone number* This field is required.Area code and phone number.
Example: +1 (250) 845-1294
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Is this PET-CT for you?* This field is required.
YESNO
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If the PET-CT is not for you, please write the patient's name:
First Name
Last Name
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Where do you currently live? (City and Country)* This field is required.We need to know where your scan needs to be done.
Example: Vancouver, British Columbia, Canada
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Are you a cancer patient, caregiver / family member, or healthcare provider?* This field is required.Select the option that best describes you.
Cancer patient
Healthcare provider
Caregiver / family member
Other
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Date of birth (Day, Month, Year)* This field is required.
Example: 12 April, 1956
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Please select which best applies to you:For medical health purposes, it is helpful for us to know this information.
Woman
Man
Intersex
MtF Female
FtM Male
Prefer not to say
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Please select your preferred pronouns:
She / her / hers
He / him / his
They / them / theirs
Ze / hir / hirs
Prefer not to say
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Current weight and height?* This field is required.
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Are you eligible for a PET-CT scan?* This field is required.There are strict requirements that dictate whether you are, or are not, eligible to get a private PET-CT scan. You need to meet one of the following criteria, in order to get a private scan in Canada.
I have a prior diagnosis of cancer.
I have a pathology report that shows a diagnosis of cancer.
I have a CT scan or an MRI that shows "suspicious" findings.
Unsure
I do not have any of the above. (Rest assured, we can still help you in this case – just with a different test. Keep filling out the form.)
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How quickly do you want your scan to be done?Select the option that best fits your needs.
As soon as possible! Less than a week
Within 2 weeks
Within a month
In about 2 months
Later – more than 2 months from now
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Are you willing to travel for a scan if it can be arranged faster outside your city?Select the option that best fits your needs.
Yes
No
Unsure – Depends how far away
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Are you willing to travel for a scan if it can be arranged for a lower cost elsewhere?Select the option that best fits your needs.
Yes
No
Unsure – Depends how far away
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What is more important to you:Select the option that best fits your needs.
Speed – I want the fastest scan possible (even if it means paying more or traveling)
Price – I want the most affordable scan possible (even if it means waiting longer or traveling)
Unsure
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Is your doctor willing to sign the requisition form for your PET-CT or PSMA-PET scan?* This field is required.Please note: It is okay if your doctor is not willing to sign the requisition form – we can solve that problem for you.
Yes, I have a doctor who is willing to sign the requisition form for my scan.
No, my doctor is NOT willing to sign the requisition form for my scan.
Unsure
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Thank you for your time so far in completing this form.

We appreciate and respect that you would like a fast and accurate assessment of whether or not you have cancer – and, if so, what the level of its aggression and location are.

Given the details you’ve provided, a PET/CT scan may not be approved at this time for you. There are strict criteria that determines who is eligible, as the previous question outlined.

Howerver, please rest assured that we can still help you: There is another leading-edge test that is even more accurate for detecting if cancer is present, which we can facilitate for you.

Please continue to fill out the form and we will ensure you get the answers you need. Thank you for your time and trust.
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Please tell us your preferred method of follow-up communication:
Phone call
Email
Text message (SMS)
Unsure
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How did you hear about us?* This field is required.Please select an option below:
Doctor or healthcare professional
Friend or family
Patient support group
Social media (Facebook, Instagram, LinkedIn, Twitter)
YouTube video
'Cancer: Just the Facts' online program
Google Search
Not sure
Other
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Is there anything else you would like to share with us?
Huge
Large
Normal
Small
Ok
Ok
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Please give us permission to email you about your PET-CT scan needs and cancer care.* This field is required.
Yes, you may email me about my PET-CT scan needs and cancer care.
No, you may not email me about my PET-CT scan needs and cancer care.
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Consent for Collection, Use, and Storage of Personal Information: * This field is required.I understand that the personal and health-related information I provide in this form, including any uploaded documents, is being collected by CTOAM for the purpose of providing PET-CT scan coordination and related cancer care support.
I agree and give my informed consent.
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Click SUBMIT to Continue Booking

After you click "Submit", you’ll receive a phone call from our team within 24 to 48 business hours (Monday to Friday 7am to 5pm Pacific Time).

After speaking with you, we will begin your PET-CT / PSMA-PET Coordination program.

If you would like to speak with someone before that, please call our medical office team at 1-778-999-5463 ext. 0.

We look forward to speaking with you very soon.

Please click SUBMIT
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