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MRI Centre Scanner Details

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This form enables Resonance Health to assess the compatibility of your MRI scanner for the FerriScan or cardiac T2* protocols. It does not constitute an agreement or contract.
Date:*
Contact Name (include title):*
Email Address:*
Position:*
Organisation:*
Street Address:*
Suburb/Area:*
Post/Zip Code:*
City:*
Country:*
Telephone Number (include area code):*
Fax Number (include area code):
Which analyses are you interested in?
Service:*	FerriScan Liver Iron Concentration only FerriScan plus Cardiac T2*
What field strength is your scanner?
Please confirm your scanner has a field strength of 1.5T. (Required for the FerriScan Protocol):*
Who is the manufacturer?
Manufacturer:*	Siemens Philips GE Other
Specify manufacturer if other:
Scanner Model:*
Software Level:*
Is your scanner equipped with a torso/chest/abdomen surface receiver coil?
Receiver Coil:*	Yes No
*Cardiac T2 only -**
Is your scanner equipped with and ECG facility and a cardiac package?:	Yes No
Is your scanner able to achieve a minimum TE between 2 & 3ms and a maximum TE between 16 & 23 ms?:	Yes No

Can you export images in DICOM 3 format?:*	Yes No
Can you send/push images to an external DICOM receiver?:*	Yes No
Can you transfer images to a networked computer with an internet connection?:*	Yes No
The following questions will provide Resonance Health with a better understanding of how we can best assist you, should you proceed with the FerriScan service.
Did your enquiry about the FerriScan R2-MRI service arise from?
Referring clinician request:
Conference attendance:
FerriScan publications:
Personal research:
Other:
Please specify if other:
How would the cost of the FerriScan service be funded at your centre (tick any that apply)?
Covered by the MRI Department:
Covered by Government reimbursement:
Charged to department / referring clinician:
Charged to a Pharmaceutical company:
Charged directly to patient:
Other:
Please specify if other:
Would you like Resonance Health to assist in marketing the FerriScan service to referring clinicians in your area?
Provide assistance?:	Yes No
Would you like to be provided with FerriScan brochures and / or other marketing material?
Provide brochures?:	Yes No
Thank you for your interest in FerriScan and Cardiac T2. We will be in contact with you shortly to advise if your MRI scanner is suitable for FerriScan / Cardiac T2.
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