STEVE BIKO ACADEMIC HOSPITAL
PR 5601738
DEPARTMENT OF NUCLEAR MEDICINE
FACULTY OF HEALTH SCIENCES
STEVE BIKO AVE
GEZINA, PRETORIA
GAUTENG
0001
PRIVATE BAG X169
PRETORIA
0001
TEL: +27(0)12 354 2273
FAX: +27(0)12 354 1219
PATIENT DETAILS
Name:
Sex:
ID number:
Cell number:
Date of birth:
Work number:
Address:
Home number:
E-mail:
RELATIVE’S DETAILS
Relative’s name:
Phone number:
Cell phone number:
MEDICAL AID DETAILS
Medical Aid Name:
Medical Aid Number:
Medical Aid Plan Option:
Medical Aid Dependant Number:
Main Member:
REFERRING DOCTORS
Referring Doctor:
General Practitioner:
Specialist:
Other referring Doctor:
Department Nuclear Medicine
University of Pretoria / Steve Biko Academic Hospital, Level F5, Bridge A, ROOM 51312
Private Bag x 169, PRETORIA, 0001
Tel: 012-354 1885 / 2273 / 2374, Fax: 012-354 1219
CLINICAL DETAILS
Diagnosis:
Treatment history (surgery, chemo, radiotherapy, sandostatin):
Current symptoms:
The results of the following special investigations have to be attached:
HISTOPATHOLOGY
1. Histology:
2. Ki-67:
IMAGING DETAILS
1. Ga-68 DOTATATE PET/CT
Or
Octreotide SPECT :
2. F-18 FDG PET/CT:
3. CT:
4. MRI:
BLOOD RESULTS
1. FBC:
2. U&E:
3. LFT:
4. Tumour marker (Chromogranin A):
Department Nuclear Medicine
University of Pretoria / Steve Biko Academic Hospital, Level F5, Bridge A, ROOM 51312
Private Bag x 169, PRETORIA, 0001
Tel: 012-354 1885 / 2273 / 2374, Fax: 012-354 1219