Radiopharmaceutical Drug
Information Consultation form
Phone
Beeper
Fax Number
Address
City
State
Zip
Contract Service
Yes RADIORX
Requestor Type:
Physician
KUMC
Institution
Community
Pharmacist
KUMC
Institution
Community
Home Health
Nurse
KUMC
Institution
Community
Home Health
Patient
KU Faculty
Other (specify below)
Other:
Name of Radiopharmaceutical
Type of scan
Description of Problem
Patient Data
Other Meds
Disease
Type of Request
Other