Nuclear Medicine - University College Hospital, Ibadan.
Nuclear Medicine Referral Form
We are a world-class Nuclear Medicine, Molecular Imaging & Theranostics clinical, training, and research centre in South West Nigeria, providing personalised imaging and therapy with radiopharmaceuticals to the West African sub-region and beyond. We are West Africa's pioneer Nuclear Medicine Centre
Patient Name
*
Surname
Name
Hospital/Folder/Case note Number
*
Patient’s Phone Number
*
Patient's Contact Number
Format: (0000) 000-0000.
Primary Working Diagnosis
*
Detailed Relevant Clinical History AND Clinical Question/Request:
Current Medication(s)
*
Other Medical AND/OR Surgical History
*
Previous Chemotherapy
*
Yes
No
Number of cycles
Please Select
1
2
3
4
5
6
7
8
9
10
Docetaxel
Start date
-
Day
-
Month
Year
Started Docetaxel
End date
-
Month
-
Day
Year
Ended Docetaxel
End date
-
Month
-
Day
Year
Ended Carbazitaxel
Previous Radiotherapy
*
Yes
No
Number of fractions
Dose
Gray
Site(s)
Radiotherapy
Date(s)
Any previous Nuclear medicine scans done ? (with us or elsewhere)
*
Yes
No
Not sure
Date
-
Day
-
Month
Year
Date
Upload available results - pathology, imaging and blood work
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Referring Clinician
*
Referring Clinician's Telephone Number
*
Mobile phone
Referring Clinician's email address
*
Email
Referring Hospital or Clinic/Speciality
*
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