T1CMR Phantom: Cardiac T1 Mapping and ECV Phantom Order form "*" indicates required fields Step 1 of 7 14% Cardiac T1 Mapping and ECV Phantom A derivative of the T1MES Academic Programme: ORDER FORMPart A – About this Order Process 1. BACKGROUND T1CMR, the Cardiac T1 Mapping and ECV Phantom (Captur G. et al. J Cardiovasc Magn Reson. 2016) was designed by a team of experts including cardiologists, physicists, engineers and national metrology institutes, led by Prof James C Moon (University College London) and Dr Peter Gatehouse (Imperial College London). Resonance Health was funded to manufacture ~70 phantoms for distribution to CMR centres worldwide, engaged in the T1 Mapping and ECV Standardisation (T1MES) in cardiovascular magnetic resonance programme which commenced in September 2015. This study is now completed and accrued data confirm phantom stability beyond 1-year (see Factsheet provided). Development of the first batch of T1MES Phantoms was funded by the European Association of Cardiovascular Imaging (EACVI), the UK National Institutes of Health Research (NIHR) and the Barts Charity, and devices were provided for free to participating study sites for the duration of the project. Each phantom, available either for 1.5T or 3T scanners, will come at a unit price of USD 7,500 to cover manufacturing and quality assurance costs. (Please note that the T1MES academic collaborators are not financially involved in any aspect of this sale but keen to support the diffusion of the project to spark new research in the field.) 2. CONDITIONS Country of Origin and Manufacture: Australia, goods manufactured by Resonance Health Analysis Services Pty Ltd (the Seller). Invoice: Invoice is sent to the billing contact provided in the form in Part B prior to production. A flat fee of USD 150 for shipping will be charged, and any import duties are to be covered by the buyer. Payment: Amount is due within 7 days from the date of invoice. Availability: Phantoms will be available immediately with an expiry date of 18 months from production. Time of shipment: As soon as payment is received by Resonance Health. Packing: Product to be packed in a new companion cardboard in polystyrene box, suitable for long distance parcel post/land and air transportation and the changes of climate, well protected against dampness, moisture, shocks and rough handling. The Seller shall be liable for any damage of the commodity due to improper packing. Insurance: Insurance to be covered by the Seller for 100% of the Invoice value covering all shipping risks. Guarantee: The products are guaranteed against any defect in material or manufacture for a period of six months from when the products are made available to the Buyer by the Seller. Repairs carried out under warranty do not extend the term of the warranty. The warranty ceases automatically if the Buyer, on his own initiative and without Seller’s express agreement, uses or modifies the product in a way not provided for nor specified by the Seller. Citation requirement: In recognition of the work put in by the T1MES team in designing and testing the original product and its prototypes, we ask that for every original research paper you publish, using the device, you kindly cite the following manuscript: Captur G, Gatehouse P, Keenan KE, Heslinga FG, Bruehl R, Prothmann M, Graves MJ, Eames RJ, Torlasco C, Benedetti G, Donovan J, Ittermann B, Boubertakh R, Bathgate A, Royet C, Pang W, Nezafat R, Salerno M, Kellman P, Moon JC. A medical device-grade T1 and ECV phantom for global T1 mapping quality assurance-the T1 Mapping and ECV Standardization in cardiovascular magnetic resonance (T1MES) program. J Cardiovasc Magn Reson. 2016 Sep 22;18(1):58 Part B –Order Form This part is to be completed by your organisationOur organisation would like to purchase: 1.5T Phantomenter quantityOur organisation would like to purchase: 3T Phantomenter quantity Organisation Information (Buyer)Site Name:* Site contact name:*(person responsible to authorise the purchase of Cardiac T1 Phantom(s)) Site contact telephone:*(with area code)Site contact email address:* Delivery Information: (Details for delivery of invoices, if different from above)Site/Department Name:* Delivery address:*(please be precise eg floor number, building number etc) Street Address Floor number, building number 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 IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic 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RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Are delivery contact name, telephone and email different from above?* Yes No Delivery contact name: Delivery contact telephone:(with area code)Delivery contact email address Billing Information: (invoice should be addressed to) Site name:* Billing contact name:* First Billing 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 IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Position Title:* Billing contact telephone:(with area code)Billing contact email address:* I have read and understood the Terms & Conditions listed in Part A 1-2, and by filling this form I agree to purchase the T1CMR Phantom(s) listed above. 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