MRI Scanner 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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Street Address (include suburb, city, country, and post/zip code) *

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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, 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)

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Email Address

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Position

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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) *

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Email Address *

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Position *

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Which service would you like to set up for your organization?

Service *

FerriScan analysis

Cardiac T2* analysis

Bone Marrow R2 analysis

Spleen R2 analysis

HepaFat-Scan

Liver Volume analysis

Spleen Volume analysis

Pancreatic Fat analysis

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What type of MRI Scanner will you use?

Manufacturer? *

Siemens

Philips

GE

Other

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Specify manufacturer if other

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Scanner Model *

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Scanner Serial *

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What field strength is your scanner?

Please confirm the field strength of your scanner *

1.5T (All services, including FerriScan®, FerriSmart, Cardiac T2*, HepaFat-Scan, and all others)
3T (Currently ONLY available for HepaFat-Scan)

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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. *

Yes

No

Unsure

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

Service Contract

Yes

No

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Cardiac T2* only

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

Yes

No

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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

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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 request

Conference attendance

Publications

Personal research

Direct contact from Resonance Health

Previously involved in a clinical trial

Other

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Please specify if other

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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

Charged to department / referring clinician

Charged to a Pharmaceutical company

Charged directly to patient

Other

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Please specify if other

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Would you like to be provided with information for referring clinicians?

Provide information?

Yes

No

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