FerriSmart Scanner Details Form

Contact Name *

Email Address *

Position (Job Title) *

Organization *

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

Country *

Telephone Number (include area code) *

Fax Number (include area code)

Will the above person be the Primary Technical Contact? – (Primary Technical Contact is responsible for technical communications with Resonance Health and if applicable, the scanning of a saline bag or test patient to verify the correct acquisition protocol has been set up.) *

Yes

No

If No, please enter the Contact Name of an appropriate Primary Technical Contact below:

Email Address

Position (Job Title)

What type of MRI Scanner will you use? *

Siemens

Philips

GE

Other

If ‘Other’, please specify manufacturer

Scanner Model? *

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

Yes

No

Unsure

Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence? *

Yes

No

Unsure

Who is your designated Super User? (A Super User has the authority to designate user access, set up billing information, and view all processed patient reports) *

Email Address *

Position (Job Title) *

How did you hear about Resonance Health? *

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 the patient

Other

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FerriSmart Scanner Details Form

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