Order

Upload Supporting Notes

We were unable to upload your file. Please ensure your file is 10MB or smaller in size.

Other History (provide details in message)

Major Surgery in last 4 weeks

Radiation Therapy in last 4 weeks

Recent G-CSF

Diabetes

Yes

No

Insulin

Oral Meds

RTP Positioning Device

Yes

No

For Cancer Patients

To Establish Diagnosis

Initial Staging

Restaging

PET/CT Scan Requested *

Whole Body FDG

Brain

Cardiac Viability

C11-Acetate

NaF-18 Bone

Amyvid

Indication *

Provider's Fax

Provider's Phone *

Ordering Provider *

Date of Birth *

Cell Phone

Home Phone *

Gender *

Male

Female

Date and time *

Repeat Patient

Yes

No

Name *

Message:

Thank you for contacting us! We will review your order and contact the patient for scheduling within 48-72 hours.

Phoenix Molecular Imaging

Call Us: 480.881.5621