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21 Oct ACG 2022 Annual Scientific Meeting, Charlotte, North Carolina

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Clinical trials:
New MRI Scanner Registration form

Please register your new MRI Scanner here.

"*" indicates required fields

Step 1 of 4

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MRI Scanner Details Form

Contact Name (include title):*

First

Email Address:*

Position / Job Title:*

Organization/ Site Name:*

Address:*

Street Address Suburb / Town State ZIP / Postal Code Country

Telephone:*

(include area code)

Fax:

(include area code)

Will the person above be the Primary Technical Contact?*

The Primary Technical Contact will be responsible for technical communications with Resonance Health and if applicable, the scanning of the FerriScan Phantom Pack (or test patient) to verify the correct acquisition protocol has been set up.

Yes

No

Please enter the contact details of an appropriate Primary Technical Contact below:

Contact Name (include title):*

First

Email Address:*

Position / Job Title:*

Data Transfer and Access to Patient Results: Please nominate the person in your organization who will have the authority to approve FAST access to others. FAST is Resonance Health’s online portal through which image data is securely transmitted to us for analysis and where the results (reports) are downloaded. It is important that we only provide access to FAST to approved staff in your organization.

Contact Name (include title):*

First

Email:*

Position / Job Title:*

Service and Scanner Details:

What service would you like to set up for your organization?*

FerriScan® analysis

Cardiac T2* analysis

Bone Marrow R2 analysis

Spleen R2* analysis

HepaFat-Scan®

Liver Volume analysis

Spleen Volume analysis

Pancreatic Fat analysis

What Manufacturer of MRI Scanner will you be setting up for using Resonance Health Services?*

Siemens

Philips

GE

Other

If other pls specify:*

Model:*

Serial number if known:

Field strength of Scanner:*

1.5T (All services, including FerriScan®, FerriSmart, Cardiac T2*, HepaFat-Scan, and all others)

3T (Currently ONLY available for HepaFat-Scan)

Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence?*

Yes

No

Unsure

Do you have a current Service Contract with your MRI manufacturer for regular maintenance?*

Yes

No

Is your scanner equipped with an ECG facility and a cardiac package with a multiple-echo T2* sequence?*

Yes

No

Is your scanner able to achieve a minimum TE≤3ms (1st TE) and a maximum TE≥16ms (8th TE) with a multi-echo gradient echo sequence?*

Yes

No

Unsure

How would the cost of the service(s) be funded at your Centre? (tick any that apply)*

Covered by the MRI Department

Covered by Government reimbursement

Charge to department/referring clinician

Charged to a Pharmaceutical company

Charged directly to the patient

Other

If other pls specify:*

How did you hear about Resonance Health?*

Conference attendance

Publications

Previously involved in a clinical trial

Personal Research

Direct contact from Resonance Health

Other

If other pls specify:*

Would you like Resonance Health to provide you with service information for referring clinicians?*

Yes

No

Complete the last step to submit the form

Prevent spam*

To send the form, please answer this question to help prevent spam: A panda is black and .....

ABN: 96 006 762 492

141 Burswood Road
Burswood WA 6100 Australia
info@resonancehealth.com

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