Clinical trials: New MRI Scanner Registration form Please register your new MRI Scanner here. Step 1 of 4 25% MRI Scanner Details FormContact Name (include title):* First Email Address:* Position / Job Title:* Organization/ Site Name:* Address:* Street Address Suburb / Town State ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 formPrevent spam*To send the form, please answer this question to help prevent spam: A panda is black and .....