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

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Welcome!

We are here to sort out all the details and make sure you can get the answers you need, ASAP.

To help you get a scan that best fits your needs, we've put together this short list of questions.

Please fill them out as best you can.

If you want to talk with a human at any time during this process, just call our medical office team: 1-778-999-5463 ext. 0.
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PET-CT / PSMA-PET Program – How it works

Step 1: Fill out this form :) Give us a few details about your scanning needs so we can direct you to the right program and location. Then click 'Submit'.

Step 2: You will receive a phone call from our team within 24 business hours (M-F). This initial phone consult helps us to understand better how we can best help you.

Step 3: We will locate the scan clinics closest to you and provide you with a short list of their fees and your appointment options – so you can choose the one that best fits your needs.

Step 4: We will coordinate your appointment with the clinic and arrange results to be sent to our team within 48 hours of your scan.

Step 5: The day before your scan, we’ll give you a call to make sure you know where to go and that all of your questions are answered.

Step 6: After your scan is complete, we will call you within 48 hours (Monday to Friday 7am to 5pm Pacific Time) to discuss the results and answer your questions about next steps as needed.

So please go ahead and continue to complete this short intake form.

Thank you!
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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 numberArea 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, what is 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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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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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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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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Click SUBMIT to Continue Booking

Thank you! You're just one step away...

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

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

If you would like to speak with someone sooner than that, just call our medical office team: 1-778-999-5463 ext. 0.

Our team will ensure that, as quickly as possible, you have the information you need to understand:
a) if you have cancer; and, if so...
b) where, exactly, the cancer is in your body and which tumors are most aggressive.

We will meet with you within 48 hours of your scan to discuss the test results and next steps. And, if needed, our team will be standing by to help advocate with your doctors to get you access to the most beneficial treatments.

We look forward to speaking with you very soon. Hope is here.

➡️ GO AHEAD, click SUBMIT 🧬
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