PET-CT Appointment

Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec

PET-CT Appointment

1		2		3		4
Choose Scan		Choose Date		Patient Details		Payment

Choose Scan *
N/A

Whole Body FDG PET-CT
PSMA Whole Body PET Scan (For Prostate)
DOPA PET-CT Scan Scan (For Parkinson's)
Whole Body FDG PET-CT with Triple Phase CT Abdomen
Brain FDG PET-CT Scan
Cardiac PET-CT for Myocardial Viability Assessment
NOTA / DOTA PET-CT (For Neuroendocrine Tumors)
N/A

Choose Location for FDG Whole Body Scan
N/A

Choose Location for your PSMA PET-CT Scan
N/A

Choose Location for your NOTA / DOTA PET-CT Scan
N/A

Choose Location for your f-DOPA Scan
N/A

Choose Location for Cardiac PET-CT Scan
If you would like to know more about the precautions, preparation or procedure for the f-DOPA PET-CT Scan, please click on DOPA PET Scan and find more information on our website.
If you would like to know more about the precautions, preparation or procedure for the PET-CT Scan, please click on Whole Body FDG PET-CT and find more information on our website.
If you would like to know more about the precautions, preparation or procedure for the PET-CT Scan, please click on PSMA PET-CT Scan and find more information on our website.
If you would like to know more about the precautions, preparation or procedure for the PET-CT Scan, please click on NOTA / DOTA PET-CT Scan and find more information on our website.

N/A

dd-MMM-yyyy

- Preferred Date for tour Scan. - Please note any appointments made after 8PM may not be confirmed for the next day.
Preferred Time for FDG Scan *
N/A

09:00 AM - 10:00 AM
09:30 AM - 10:30 AM
10:00 AM-11:00 AM
11:00 AM - Noon

Preferred Time for FDG Scan
N/A

dd-MMM-yyyy

- Preferred Date for your PSMA Scan. - Please note any appointments made after 8PM may not be confirmed for the next day.
Preferred Time for PSMA Scan *
N/A

12:30 PM - 01:30 PM

Preferred Time for PSMA Scan
Preferred Time for NOTA Scan *
N/A

12:30 PM - 01:30 PM

Preferred Time for NOTA / DOTA Scan
N/A

dd-MMM-yyyy

- Preferred Date for your NOTA / DOTA Scan. - Please note any appointments made after 8PM may not be confirmed for the next day.
N/A

dd-MMM-yyyy

- Preferred Date for your f-DOPA Scan. - Please note any appointments made after 8PM may not be confirmed for the next day.
Preferred Time for DOPA Scan *
N/A

12:30 PM - 01:30 PM

Preferred Time for DOPA Scan

Patient Name
N/A

Required First Name Last Name
Age (In Years) *
N/A
Gender *
N/A

Male
Female
Mobile Number *
N/A

+91
Referred By *
N/A
Email *
N/A
Doctor Prescription
N/A
Upload file
Please upload Dr Prescription
Clinical History
N/A

Please enter any medical history relevant to your case.

Confirm Booking
Price for PSMA PET-CT Scan INR *
N/A
Price for F-DOPA PET-CT Scan INR *
N/A
Price for F-NOTA PET-CT Scan INR *
N/A
Price for Whole Body FDG PET-CT Scan- Faridabad INR *
N/A
Price for Whole Body FDG PET-CT Scan INR *
N/A
Price for Cardiac PET-CT Scan INR *
N/A
Price for Whole body FDG PET-CT with Triple phase CT Abdomen Scan INR *
N/A
Price for Whole body FDG PET-CT with Triple phase CT Abdomen Scan For Faridabad INR *
N/A
Price for Brain FDG PET-CT INR *
N/A
Advance Amount *

Razorpay INR

Amount to be paid ₹
Important Information

Appointment Time Slot: Please note that your chosen time is not confirmed. You will receive a callback and/or email on the day before your scan to confirm the final time slot. We will try to accommodate you to your preferred time. Time slots are adjusted based on emergencies, comorbidities etc. Please also note that a booking made after 8:30pm may not be confirmed for the next day.

Refund Policy: Please note that the amount paid for booking can not in be refunded in the case of a no-show as the radio-pharmaceutical medical dose procured for you will get wasted due to it's short half-life of the produced isotopes. If you wish to cancel or reschedule your appointment, you must inform us at-latest by 8.30pm on the day prior to your appointment so that we do not order the medicine for your scan. In case of an untimely cancellation an amount of Rs. 5000 will be deducted on account of dose wastage.

Pre-Test Preparation: Please read the pre-test preparation on the next page after your confirmation to ensure that that you follow the necessary precautions for your scan.
For Information on PET Scan Cost, Procedure or Precautions, please visit the PET CT Scan facility page on the House Of Diagnostics Website for more information.

1/4

2/4

3/4

4/4

Error Occurred

You haven't verified your email yet, click here to receive a verification email.

This file format is not supported by your browser for preview.

That CAPTCHA was incorrect.

Your form has been deactivated. Contact support@zohoforms.com for further information.

Submitting...

Please Wait...

Saving...

Redirecting to Merchant Website..

Verifying Credit Card Details...

Please wait...

Loading payment widget...

Verification Code

Enter the text in the box below

Please wait

Verification mail sent.

Link to resume this form later:

Email Link to

Please enter a valid email address to configure Zoho Sign settings.

Copy Link Copied to clipboard.

Turn on the camera permission in your browser to continue further

Submission Not Allowed

You need to verify your email address to submit form