FerriSmart Details Form - Resonance Health

Contact Name (include title) *

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Email Address *

Please let us know your email address.

Position *

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Organisation *

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Department *

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Street Address *

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Suburb/Area *

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Post/Zip Code *

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City *

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Country *

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Telephone Number (include area code) *

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Fax Number (include area code)

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Will this person be the Primary Technical Contact?

Primary Technical Contact? *

Yes
No

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

If not, please enter contact details of an appropriate Primary Technical Contact.

Contact Name (include title)

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Email Address

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Position

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Which analyses are you interested in?

Service *

FerriSmart Liver Iron Concentration

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What field strength is your scanner?

Please confirm your scanner has a field strength of 1.5T? *

Yes

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Manufacturer *

Siemens
Philips
GE
Other

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Who is the manufacturer?

Specify manufacturer if other

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Scanner Model *

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Can your scanner achieve a minimum TE of 6.0ms (single spin echo)? (for FerriSmart)

TE of 6.0ms? *

Yes
No
Unsure

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Software Level *

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Is your scanner equipped with a torso/chest/abdomen/cardiac surface receiver coil?

Receiver Coil:

Yes
No

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Who is your designated Super User?

The Super User will be responsible for the managing of an organisation on the Resonance Health web portal. These responsibilities include creating users and granting access to the portal service, setting up billing and payment information, viewing all completed and rejected jobs processed by all users, and the general management of an organisation and their scanner verification status.

Please nominate the person in your organisation who has the authority to designate user access, set up billing information, and view all processed patient reports.

Contact Name (include title) *

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Email Address *

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Position *

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Did your enquiry about Resonance Health services arise from..

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Please specify if other

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