Home | Information for Radiology Centres | MRI Scanner Details Form MRI Scanner Details Form Contact Name (include title) * Invalid Input Email Address * Please let us know your email address. Position * Invalid Input Organisation * Invalid Input Street Address (include suburb, city, country, and post/zip code) * Invalid Input Telephone Number (include area code) * Invalid Input Fax Number (include area code) Invalid Input Will this person be the Primary Technical Contact? Primary Technical Contact? * YesNoInvalid Input (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.) If not, please enter contact details of an appropriate Primary Technical Contact. Contact Name (include title) Invalid Input Email Address Invalid Input Position Invalid Input Data Transfer and Access to Patient Results Please nominate the person in your organisation 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 organisation. Contact Name (include title) * Invalid Input Email Address * Invalid Input Position * Invalid Input Which service would you like to set up for your organization? Service * FerriScan Liver Iron Concentration onlyFerriScan plus Cardiac T2*HepaFat-ScanInvalid Input What type of MRI Scanner will you use? Manufacturer? * SiemensPhilipsGEOtherInvalid Input Specify manufacturer if other Invalid Input Scanner Model * Invalid Input What field strength is your scanner? Please confirm your scanner has a field strength of 1.5T? * YesInvalid Input Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence? This is an important requirement for the FerriScan service. * YesNoUnsureInvalid Input Do you have a current Service Contract with your MRI manufacturer for regular maintenance? Service Contract YesNoInvalid Input Cardiac T2* only Is your scanner equipped with an ECG facility and a cardiac package with a multi-echo T2* sequence? YesNoInvalid Input 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? YesNoUnsureInvalid Input The following questions will provide Resonance Health with a better understanding of how we can best assist you, should you proceed with our services. How did you hear about Resonance Health? Referring clinician requestConference attendancePublicationsPersonal researchDirect contact from Resonance HealthPreviously involved in a clinical trialOtherInvalid Input Please specify if other Invalid Input How would the cost of the service(s) be funded at your centre (tick any that apply)? Covered by the MRI DepartmentCovered by Government reimbursementCharged to department / referring clinicianCharged to a Pharmaceutical companyCharged directly to patientOtherInvalid Input Please specify if other Invalid Input Would you like to be provided with information for referring clinicians? Provide information? YesNoInvalid Input
