BIRATNAGAR ASPATAL PVT. LTD.

BIRAT MEDICAL COLLEGE TEACHING HOSPITAL

Patient Name:.................................................................................................................................
Hospital No.:..............................................
Address:............................................................................................................................................
Age/Sex:......................................................
Date/Time:.................................
Diagnosis:..............................................................................................................................................
Clinical History: NM No.

Consultant

I/C Routine

Follow Up

Urgent

Previous

Study

Previous Study No

Pregnancy

LMP
If Specific Information
Required Breast Feeding Status

OSTEOLOGY
DEXA SCAN Lympho-scintigraphy
WB Bone Scan with SPECT-CT
Whole Body DEXA Scan Lympho-scintigraphy (Upper/Lower
3 Phase Bone Scan with Lumber Spine with Hip Joint DEXA Scan Limbs)
SPECT-CT
Hip Joint with spine DEXA Scan Sentinel Lymph node mapping
GENITO-URINARY
Radio-Nuclide Mammography
Static Renal Scan (DMSA) GASTRO AND HEPATOBILIARY. NEUROSCIENCES
Dynamic Renal Scan (DTPA) Gastro-Esophageal Reflux Study (G.E.R. Brain Perfusion SPECT Scan
Dynamic Renal Scan with Study)
Radionuclide Cisternography for CSf leak
Diuretic Gastro-intestinal Bleed (G.I.B.)
PULMONARY
Dynamic Renal Scan with Hepato-biliary Scintigraphy (HIDA)
Captopril Lung Ventilation & Perfusion Scan
Meckel's Scan with 99mTc Pertechnetate (V/Q Scan)
Testicular Scan Hepato-splenic Scintigraphy Lung Ventilation Scan.
Direct Radionuclide Gastric Emptying Time (GET) Study
Cystourethrography (D.R.C.G.) RADIO-ISOTOPE THERAPY
Salivary Gland Scintigraphy Radio-Iodine therapy of Thyroid
ENDOCRINOLOGY
Thyroid Uptake with I-131 CARDIOLOGY Cancer
Iodine Stress/Rest Myocardial Perfusion Radio-Iodine therapy of Thyroid Toxic
Thyroid Scan with 99mTc Scintigraphy Radio-Isotope therapy of
Iodine-131 Whole Body Scan Venography (Radionuclide) Prostate
Whole Body Scan with Radionuclide Ventriculography Radio-Isotope therapy of Neuro
M.I.B.G. (M.U.G.A. Scan)
Endocrine tumors
Parathyroid Scan
Radio-Isotope therapy for
metastatic bone pain
palliation
INSTRUCTIONS TO THE PATIENT:
1. On the day of appointment come along with this requisition form.
2. Please be sure to be punctual. If you cannot come or need to change your appointment,
you must inform us as soon as possible so that another patient can be
accomodated for investigation.
3. Please bring all your previous clinical records and investigation reports.
4. Female patients must declare their pregnancy status. Even suspicion of pregnancy must
be revealed.
5. Breast feeding mothers should take instruction form the examining doctor to know when
brfeastfeeding can be restarted.
6. After your clinical examination, you will be called for administration of a radiotracer.
After that you have to wail till you are called for investigation.
7. Your waiting period to complete the entire investigation may be as long as 6 hours. So
please bring food or drink as required
8. Please do not leave the department until you are asked to do so. Sometimes the
investigation may have to be repeated for satisfactory results.
9. The radio-isotope for for your investigation comes from abroad (Turkey). Sometimes due
to unavoidable circumstances, it may not arrive in time. In such a case you will be
given a new date for the investigation.
10. Usually no prior preparation is required. Usual breakfast can be taken if not otherwise
advised.

Special Preparation / Instruction if any: