NB: This procedure does not apply to referrals for PET/CT which is provided by a private company (Alliance Medical).

• Referrals for nuclear cardiology exams (myocardial perfusion scintigraphy, radionuclide ventriculography) should be by an electronic request (via WebV).
• All other referrals for nuclear medicine procedures should be submitted on the orange stripe NUCLEAR MEDICINE request form.
• Check the referral criteria for the procedure you are requesting to ensure you are entitled to refer and that the procedure is suitable for the clinical question.
  • In general referrals are only accepted from UK Registered Medical Practitioners. Referrals from non-medical staff will be accepted only from those previously approved. A list of approved non-medical referrers is kept in the nuclear medicine department (SOP E019).
  • Check the contraindications including any medication which might interfere with the procedure.
  • Some procedures require the administration of other, non-radioactive pharmaceuticals as an essential part of the procedure. These are specified in the referral criteria. Your request for an investigation will be taken as implying agreement to the administration of the specified supplementary drug. If you are unhappy about your patient being given these drugs or you feel they are contraindicated this must be clearly stated on the request.
  • Links to referral criteria for each type of nuclear medicine procedure are provided below. These include valid clinical indications, contraindications, and any supplementary drugs used in the procedure. Please contact the Nuclear Medicine Department on 0303 330 4535 or nlg-tr.gymedicalphysicsadmin@nhs.net for advice on any procedure or clinical indications not covered by this document.
  • You MUST provide sufficient information for the ARSAC licence holder to justify the radiation dose to the patient
• If a referral needs to be cancelled, phone the nuclear medicine department on 0303 330 4535 to inform us of the cancellation, to ensure the patient does not receive an unnecessary radiation dose.

As referrer you must provide the following information on the request:

• Sufficient medical data (such as previous diagnostic information or medical records) relevant to the procedure requested to enable the ARSAC Licence holder to decide whether there is a sufficient net benefit to the patient (Requirement under the Ionising Radiation [Medical Exposures] Regulations).
• The clinical question.
• The suggested procedure (e.g. Bone Scan, Myocardial Perfusion Scan).
• Sufficient information to identify the patient:
  • for paper requests, ensure the full name, address, date of birth, and a numeric identifier (e.g. NHS number) are included.
• Whether the patient is pregnant or breastfeeding.
  • Therapy Procedures
    • Pregnant patients must not be referred for therapy procedures.
    • Ensure that the patient is aware of the importance of not being pregnant at the time of the therapy procedure and discuss appropriate contraception if necessary.
    • Ensure that the patient is aware of the need to avoid becoming pregnant after the therapy for a period of time dependent on the therapy (6 months for I-131 therapy) .
• Any relevant medication (see referral criteria for any medication which might interfere with the procedure and indicate if it can be stopped).
• If the patient has a catheter or is incontinent.
• Any language or communication difficulties.
• Any conditions that might make it difficult for the patient to comply with the procedure (e.g. difficulties in lying flat).
• Any medical or other potential risks to staff.
• Name of clinical trial/research project (if applicable).
• Sufficient information to identify you as referrer.
  • For electronic requests, ensure the request is made under your own login.
  • For paper requests you must sign and legibly PRINT your name and job title.

Bone Scan

Malignant Otitis Externa (Gallium Scan)

Radionuclide Ventriculography

Myocardial Perfusion Imaging

Lung Ventilation/Perfusion Imaging

DMSA Kidney Imaging

Diuretic Renogram

Gastric Emptying

Gastro-Intestinal Bleeding Scintigraphy

Meckel's Diverticulum Imaging

HIDA

Parathyroid Localisation Imaging

Thyroid Imaging and Uptake Measurement with I-123

Tc99m Pertechnetate Thyroid Imaging

Tc99m Tektrotyd (Octreotide) Somatostatin Receptor Imaging

MIBG Tumor imaging

Thyroid Metastases Imaging (I123 Whole Body Scan)

Sentinel Node Breast

Lymphoscintigraphy

DaTSCAN

Lacrimal Scintigraphy

Salivary Gland Scan

SeHCAT

Radioiodine Treatment of Thyrotoxicosis