PHYSICIAN FORMS

CareImaging LP (CARE) is conducting a Phase III Health Canada approved clinical trial. Doctors wishing to participate in the trial must first be authorized as a referring physician by reading, signing and faxing in the Physician Information and Consent Form. This only needs to be completed once.

To refer a patient the physician needs to complete a PET Referral Form for each patient.

Referred patients will be contacted directly to schedule an appointment.

Report from scan will be faxed to referring physician.

CARE will fax a copy of the Follow up Questionnaire to the referring physician for completion 6 months after patient has been scanned. This completes physician’s participation in the clinical trial.

Forms:

1. Physician Information and Consent Form
2. PET Referral Form
3. Follow up Questionnaire
4. Clinical Trial Guidelines