Request Forms & Online Referral

If you would like to fill these forms in on your computer, please download the file and open it in Adobe Acrobat Reader and not in your browser. Alternatively, refer directly online using the fields below.

Instaferrals (Direct Online Referrals)

Referral date

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Patient Name *

First

Last

OR take / upload picture of patient sticker or registration document

Click or drag a file to this area to upload.

In-patient Hospital Number

Location

Patient's Email Addresss *

Mobile Phone

Diagnosis (ICD-10) *

Description of Clinical Problem (History & Examination)

Supporting documents – histology (compulsory in oncology referrals) *

e.g. blood results, reports, interventions etc

Supporting documents – other *

e.g. blood results, reports, interventions etc

Supporting documents – other *

e.g. blood results, reports, interventions etc

Investigation requestedTc-99m PSMA SPECT-CT for prostate cancer (see PET-CT for Ga-68 and F-18 PSMA)PET-CTBone scan + SPECT-CTBrain scan for dementia, Parkinsonism, SLEGastric emptying for gastroparesisGastrointestinal bleeding (high sensitivity occult bleeding)Hepatobiliary imaging (-IDA derivatives) e.g. DISIDA/HIDAInfection imaging (discuss prior to referring)Lymphoscintigraphy to assess lymphatic drainageMilkscan is assess gastro-oesophageal refluxMUGA scan for left ventricular ejection fractionMyocardial perfusion imaging (MPI) e.g. MIBI/CardioliteParathyroid scanPerfusion-only LUNG scan (quantitative)Renal scintigraphy/Renogram (e.g. DTPA, MAG3)Salivagram to assess for aspirationSentinel lymph node mapping + SPECT-CTThyroid scanVentilation-Perfusion scan (VQ) for PTE, CTEPH (+ follow-up)Other

PET-CT type *F-18 FDG general oncologyF-18 FDG general oncology + same-day MUGA for LVEFF-18 FDG lymphoma (x3 – baseline, interim PET and end-of-therapy)F-18 FDG lymphoma (above) + same-day MUGA for LVEFF-18 PSMA scan for prostate cancer (limited to specific days)Ga-68 PSMA scan for prostate cancer (available daily)Ga-68 DOTATATE scan for neuroendocrine tumours/meningiomaF-18 DOPA for neuroendocrine tumours

Oncology PET-CT indication *

• Staging scan
• Restaging scan
• Suspected recurrence/Restaging scan
• Monitoring of treatment response
• Biopsy site localization

This information is mandatory (by medical schemes).

Other GIT motility optionsOptionalGastric emptying scan onlyGI-motility (swallow phase, gastric emptying + colonic transit)Colonic transit study onlyMilkscan onlyMilkscan + salivagram for aspiration

Myocardial Perfusion Imaging Options *OptionalRegular – stress MPI + rest MPI for ischaemiaChest pain assessment – stress MPI + Q-only lung SPECT-CTGuided cardiac assessment – rest MPI +/- stress MPI/viability scan

VQ scan options *OptionalHigh sensitivity VQ SPECT-CT for acute PTEPlanar VQ scan to exclude PTE, prognosticate & guide treatmentCombination of high-sensitivity SPECT-CT & planar VQChest pain assessment – stress MPI + Q-only lung SPECT-CTCTEPH protocol – diagnosis + follow-up at 3 months for prognosticationQ-only scan for lung function prior to lobectomy

Other scan type (please specify or describe desired outcome)

Referring Physician *

First

Last

Speciality OR Field-of-interest

PCNS/BHF Number

HPCSA Number

13-digit ID number *

Physicians Primary Email Address *

This address has to be a direct email so that the report can be forwarded directly to the treating physician as per POPI act requirements.

Secondary Email (Reception) OR Other doctors to Cc

Optional

Submit