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68Ga-DOTA-TATE (NetSpot) PET/CT Order Form/Patient History Indiana University School of Medicine Patient Name: _____________________________________ Gender: M F Patient I.D. ____________________ Date of Birth: ________________________ Referring Physician: _________________________________________________________________ Specify the indication for a 68Ga-DOTA-TATE (NetSpot) PET/CT scan in this patient:* ☐ NEN patient, who is a potential candidate for multi-visceral organ transplant (MVOT), to determine extent of disease ☐ Patient with biopsy-proven NEN or NESSTR, where there is clinical need to determine extent of disease or location of unknown primary ☐ Patient with strong clinical suspicion of NEN or NESSTR, but no tumor location is known ☐ Patient with NEN or NESSTR who has had disease-specific treatment, and where there is clinical need to establish interim response to therapy or evaluate for disease recurrence * Intended for Neuroendocrine Neoplasia (NEN) or other neoplasms expressing somatostatin receptors (NESSTR), such as astrocytomas and meningiomas in the brain; adrenal medullary tumors (pheochromocytoma, neuroblastoma, ganglioneuroma), medullary thyroid cancer, renal cell cancer, pituitary adenomas, paragangliomas, and patients with primary tumor-induced osteomalacia. 68Ga-DOTA-TATE specifically targets SSTR2. If the tumor is expected to primarily express SSTR3, SSTR4, or SSTR5, 68Ga-DOTA-NOC may be more appropriate. 68Ga-DOTA-NOC may also be more appropriate, if the patient is being followed longitudinally and has a prior 68Ga-DOTA-NOC scan. Have we performed a prior PET/CT study on this patient using Expanded Access Is a contrast-enhanced CT scan indicated, independent of the 68Ga-DOTA-TATE 68Ga-DOTA-NOC? study? ☐Y ☐Y ☐N ☐N Is patient receiving Octreotide, Lanreotide, or other somatostatin-receptor-binding drug, therapeutically? ☐ Y ☐ N If yes, Drug: __________________________________ Dose: ________________________ Date of last administration: _____________________________ Date of next planned administration: ______________________ Scan date should be coordinated to occur just prior to the next planned dose. Other relevant medical history: ___________________________________________________________ ____________________________________________________________________________________ Referring Physician’s Clinical Objectives for this Diagnostic Study:_______________________________ ____________________________________________________________________________________ NOTE 1: NetSpot (68Ga-DOTA-TATE) is an FDA-approved radiopharmaceutical for PET evaluation of patients with neuroendocrine tumors. PET/CT scan. But, it may be necessary to obtain pre-authorization from the patient’s insurance to cover this imaging procedure. Ordering Physician: _____________________________ 12/29/2016 Date: ______________