THERAPY REPORT FORM

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Include the following items in a letter format:

Patient's Name and ID. Name of Referring Physician. Date of signature of Informed Consent.

Date of procedure and Institution Name performing the examinations.

Dear Dr (Name of Referring Physician):

The result of the (Procedure) performed on (Patient's Name ), is as follows:

Clinical History: Patient's  age and gender, diagnosis or referral information. Add any other relevant data. In the case of females, note how pregnancy was ruled out (e.g. subBeta GCH). For 131-I cancer therapy write down value of TSH. For 131-I hyperthyroidism therapy write down value of RAIU.

Quality Control: Describe procedures in this regard (especially for Radiopharmaceutical). Radiopharmaceutical dose.

Comments: Any event which might affect the therapeutic procedure being performed is listed here.

Directions after Treatment: Note in detail clinical and radioprotection measures to the patient and relatives. Likewise any follow up test to be carried out, e.g. Whole Body Scan.


Dr (Name of Reporting Physician). Name of Physician validating the report.
e-mail and Cel Phone.


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