{"id":852,"date":"2019-11-01T02:04:39","date_gmt":"2019-11-01T02:04:39","guid":{"rendered":"https:\/\/ferriscan.com\/?page_id=852"},"modified":"2020-05-01T00:30:11","modified_gmt":"2020-05-01T00:30:11","slug":"mri-scanner-details-form","status":"publish","type":"page","link":"https:\/\/ferriscan.com\/mri-scanner-details-form\/","title":{"rendered":"MRI Scanner Details Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"852\" class=\"elementor elementor-852\" data-elementor-settings=\"[]\">\n\t\t\t\t\t\t\t<div class=\"elementor-section-wrap\">\n\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-790f5f7 elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"790f5f7\" data-element_type=\"section\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[{&quot;jet_parallax_layout_image&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;},&quot;_id&quot;:&quot;9822bb5&quot;,&quot;jet_parallax_layout_image_tablet&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_mobile&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;},&quot;jet_parallax_layout_speed&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:50,&quot;sizes&quot;:[]},&quot;jet_parallax_layout_type&quot;:&quot;scroll&quot;,&quot;jet_parallax_layout_z_index&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x&quot;:50,&quot;jet_parallax_layout_bg_y&quot;:50,&quot;jet_parallax_layout_bg_size&quot;:&quot;auto&quot;,&quot;jet_parallax_layout_animation_prop&quot;:&quot;transform&quot;,&quot;jet_parallax_layout_on&quot;:[&quot;desktop&quot;,&quot;tablet&quot;],&quot;jet_parallax_layout_direction&quot;:null,&quot;jet_parallax_layout_fx_direction&quot;:null,&quot;jet_parallax_layout_bg_x_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_mobile&quot;:&quot;&quot;}],&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-7b010ca\" data-id=\"7b010ca\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-03f5a3b elementor-widget elementor-widget-spacer\" data-id=\"03f5a3b\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-b5355df elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"b5355df\" data-element_type=\"section\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[{&quot;jet_parallax_layout_image&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;},&quot;_id&quot;:&quot;a45d329&quot;,&quot;jet_parallax_layout_image_tablet&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_mobile&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;},&quot;jet_parallax_layout_speed&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:50,&quot;sizes&quot;:[]},&quot;jet_parallax_layout_type&quot;:&quot;scroll&quot;,&quot;jet_parallax_layout_z_index&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x&quot;:50,&quot;jet_parallax_layout_bg_y&quot;:50,&quot;jet_parallax_layout_bg_size&quot;:&quot;auto&quot;,&quot;jet_parallax_layout_animation_prop&quot;:&quot;transform&quot;,&quot;jet_parallax_layout_on&quot;:[&quot;desktop&quot;,&quot;tablet&quot;],&quot;jet_parallax_layout_direction&quot;:null,&quot;jet_parallax_layout_fx_direction&quot;:null,&quot;jet_parallax_layout_bg_x_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_mobile&quot;:&quot;&quot;}]}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-5fb14e6\" data-id=\"5fb14e6\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-62ec956 elementor-widget elementor-widget-heading\" data-id=\"62ec956\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">MRI Scanner Details Form<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-ad9b62b elementor-widget elementor-widget-text-editor\" data-id=\"ad9b62b\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t<p><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_2_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form \" id=\"form_mri-scanner-details-form\"  >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">MRI Scanner Details Form<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"2\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_2\" id=\"frm_hide_fields_2\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"mri-scanner-details-form\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_2\" name=\"frm_submit_entry_2\" value=\"73a80c6183\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/852\" \/><div id=\"frm_field_6_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_qh4icy2\" id=\"field_qh4icy2_label\" class=\"frm_primary_label\">Contact Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_qh4icy2\" name=\"item_meta[6]\" value=\"\"  data-reqmsg=\"Contact Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_7_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_ocfup12\" id=\"field_ocfup12_label\" class=\"frm_primary_label\">Email Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_ocfup12\" name=\"item_meta[7]\" value=\"\"  data-reqmsg=\"Email Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_q5qeq\" id=\"field_q5qeq_label\" class=\"frm_primary_label\">Position (Job Title)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_q5qeq\" name=\"item_meta[11]\" value=\"\"  data-reqmsg=\"Position (Job Title) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_12_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_qj9hz\" id=\"field_qj9hz_label\" class=\"frm_primary_label\">Organization\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_qj9hz\" name=\"item_meta[12]\" value=\"\"  data-reqmsg=\"Organization cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_13_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_2yt7u\" id=\"field_2yt7u_label\" class=\"frm_primary_label\">Street Address (include suburb, city, and zip\/post code)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_2yt7u\" name=\"item_meta[13]\" value=\"\"  data-reqmsg=\"Street Address (include suburb, city, and zip\/post code) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_31_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_hg9r8\" id=\"field_hg9r8_label\" class=\"frm_primary_label\">Country\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[31]\" id=\"field_hg9r8\"  data-reqmsg=\"Please select your Country.\" aria-required=\"true\" data-invmsg=\"Country is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"Afghanistan\">Afghanistan<\/option><option  value=\"Aland Islands\">Aland Islands<\/option><option  value=\"Albania\">Albania<\/option><option  value=\"Algeria\">Algeria<\/option><option  value=\"American Samoa\">American Samoa<\/option><option  value=\"Andorra\">Andorra<\/option><option  value=\"Angola\">Angola<\/option><option  value=\"Anguilla\">Anguilla<\/option><option  value=\"Antarctica\">Antarctica<\/option><option  value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option  value=\"Argentina\">Argentina<\/option><option  value=\"Armenia\">Armenia<\/option><option  value=\"Aruba\">Aruba<\/option><option  value=\"Australia\">Australia<\/option><option  value=\"Austria\">Austria<\/option><option  value=\"Azerbaijan\">Azerbaijan<\/option><option  value=\"Bahamas\">Bahamas<\/option><option  value=\"Bahrain\">Bahrain<\/option><option  value=\"Bangladesh\">Bangladesh<\/option><option  value=\"Barbados\">Barbados<\/option><option  value=\"Belarus\">Belarus<\/option><option  value=\"Belgium\">Belgium<\/option><option  value=\"Belize\">Belize<\/option><option  value=\"Benin\">Benin<\/option><option  value=\"Bermuda\">Bermuda<\/option><option  value=\"Bhutan\">Bhutan<\/option><option  value=\"Bolivia\">Bolivia<\/option><option  value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\">Botswana<\/option><option  value=\"Bouvet Island\">Bouvet Island<\/option><option  value=\"Brazil\">Brazil<\/option><option  value=\"Brunei\">Brunei<\/option><option  value=\"Bulgaria\">Bulgaria<\/option><option  value=\"Burkina Faso\">Burkina Faso<\/option><option  value=\"Burundi\">Burundi<\/option><option  value=\"Cambodia\">Cambodia<\/option><option  value=\"Cameroon\">Cameroon<\/option><option  value=\"Canada\">Canada<\/option><option  value=\"Cape Verde\">Cape Verde<\/option><option  value=\"Cayman Islands\">Cayman Islands<\/option><option  value=\"Central African Republic\">Central African Republic<\/option><option  value=\"Chad\">Chad<\/option><option  value=\"Chile\">Chile<\/option><option  value=\"China\">China<\/option><option  value=\"Colombia\">Colombia<\/option><option  value=\"Comoros\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Costa Rica\">Costa Rica<\/option><option  value=\"C\u00f4te d&#039;Ivoire\">C\u00f4te d&#039;Ivoire<\/option><option  value=\"Croatia\">Croatia<\/option><option  value=\"Cuba\">Cuba<\/option><option  value=\"Curacao\">Curacao<\/option><option  value=\"Cyprus\">Cyprus<\/option><option  value=\"Czech Republic\">Czech Republic<\/option><option  value=\"Denmark\">Denmark<\/option><option  value=\"Djibouti\">Djibouti<\/option><option  value=\"Dominica\">Dominica<\/option><option  value=\"Dominican Republic\">Dominican Republic<\/option><option  value=\"East Timor\">East Timor<\/option><option  value=\"Ecuador\">Ecuador<\/option><option  value=\"Egypt\">Egypt<\/option><option  value=\"El Salvador\">El Salvador<\/option><option  value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option  value=\"Eritrea\">Eritrea<\/option><option  value=\"Estonia\">Estonia<\/option><option  value=\"Ethiopia\">Ethiopia<\/option><option  value=\"Fiji\">Fiji<\/option><option  value=\"Finland\">Finland<\/option><option  value=\"France\">France<\/option><option  value=\"French Guiana\">French Guiana<\/option><option  value=\"French Polynesia\">French Polynesia<\/option><option  value=\"Gabon\">Gabon<\/option><option  value=\"Gambia\">Gambia<\/option><option  value=\"Georgia\">Georgia<\/option><option  value=\"Germany\">Germany<\/option><option  value=\"Ghana\">Ghana<\/option><option  value=\"Gibraltar\">Gibraltar<\/option><option  value=\"Greece\">Greece<\/option><option  value=\"Greenland\">Greenland<\/option><option  value=\"Grenada\">Grenada<\/option><option  value=\"Guadeloupe\">Guadeloupe<\/option><option  value=\"Guam\">Guam<\/option><option  value=\"Guatemala\">Guatemala<\/option><option  value=\"Guernsey\">Guernsey<\/option><option  value=\"Guinea\">Guinea<\/option><option  value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option  value=\"Guyana\">Guyana<\/option><option  value=\"Haiti\">Haiti<\/option><option  value=\"Honduras\">Honduras<\/option><option  value=\"Hong Kong\">Hong Kong<\/option><option  value=\"Hungary\">Hungary<\/option><option  value=\"Iceland\">Iceland<\/option><option  value=\"India\">India<\/option><option  value=\"Indonesia\">Indonesia<\/option><option  value=\"Iran\">Iran<\/option><option  value=\"Iraq\">Iraq<\/option><option  value=\"Ireland\">Ireland<\/option><option  value=\"Israel\">Israel<\/option><option  value=\"Italy\">Italy<\/option><option  value=\"Jamaica\">Jamaica<\/option><option  value=\"Japan\">Japan<\/option><option  value=\"Jersey\">Jersey<\/option><option  value=\"Jordan\">Jordan<\/option><option  value=\"Kazakhstan\">Kazakhstan<\/option><option  value=\"Kenya\">Kenya<\/option><option  value=\"Kiribati\">Kiribati<\/option><option  value=\"North Korea\">North Korea<\/option><option  value=\"South Korea\">South Korea<\/option><option  value=\"Kosovo\">Kosovo<\/option><option  value=\"Kuwait\">Kuwait<\/option><option  value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option  value=\"Laos\">Laos<\/option><option  value=\"Latvia\">Latvia<\/option><option  value=\"Lebanon\">Lebanon<\/option><option  value=\"Lesotho\">Lesotho<\/option><option  value=\"Liberia\">Liberia<\/option><option  value=\"Libya\">Libya<\/option><option  value=\"Liechtenstein\">Liechtenstein<\/option><option  value=\"Lithuania\">Lithuania<\/option><option  value=\"Luxembourg\">Luxembourg<\/option><option  value=\"Macao\">Macao<\/option><option  value=\"Macedonia\">Macedonia<\/option><option  value=\"Madagascar\">Madagascar<\/option><option  value=\"Malawi\">Malawi<\/option><option  value=\"Malaysia\">Malaysia<\/option><option  value=\"Maldives\">Maldives<\/option><option  value=\"Mali\">Mali<\/option><option  value=\"Malta\">Malta<\/option><option  value=\"Marshall Islands\">Marshall Islands<\/option><option  value=\"Martinique\">Martinique<\/option><option  value=\"Mauritania\">Mauritania<\/option><option  value=\"Mauritius\">Mauritius<\/option><option  value=\"Mayotte\">Mayotte<\/option><option  value=\"Mexico\">Mexico<\/option><option  value=\"Micronesia\">Micronesia<\/option><option  value=\"Moldova\">Moldova<\/option><option  value=\"Monaco\">Monaco<\/option><option  value=\"Mongolia\">Mongolia<\/option><option  value=\"Montenegro\">Montenegro<\/option><option  value=\"Montserrat\">Montserrat<\/option><option  value=\"Morocco\">Morocco<\/option><option  value=\"Mozambique\">Mozambique<\/option><option  value=\"Myanmar\">Myanmar<\/option><option  value=\"Namibia\">Namibia<\/option><option  value=\"Nauru\">Nauru<\/option><option  value=\"Nepal\">Nepal<\/option><option  value=\"Netherlands\">Netherlands<\/option><option  value=\"New Caledonia\">New Caledonia<\/option><option  value=\"New Zealand\">New Zealand<\/option><option  value=\"Nicaragua\">Nicaragua<\/option><option  value=\"Niger\">Niger<\/option><option  value=\"Nigeria\">Nigeria<\/option><option  value=\"Norway\">Norway<\/option><option  value=\"Northern Mariana Islands\">Northern Mariana Islands<\/option><option  value=\"Oman\">Oman<\/option><option  value=\"Pakistan\">Pakistan<\/option><option  value=\"Palau\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\">Panama<\/option><option  value=\"Papua New Guinea\">Papua New Guinea<\/option><option  value=\"Paraguay\">Paraguay<\/option><option  value=\"Peru\">Peru<\/option><option  value=\"Philippines\">Philippines<\/option><option  value=\"Pitcairn\">Pitcairn<\/option><option  value=\"Poland\">Poland<\/option><option  value=\"Portugal\">Portugal<\/option><option  value=\"Puerto Rico\">Puerto Rico<\/option><option  value=\"Qatar\">Qatar<\/option><option  value=\"Romania\">Romania<\/option><option  value=\"Russia\">Russia<\/option><option  value=\"Rwanda\">Rwanda<\/option><option  value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\">Saint Lucia<\/option><option  value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\">Samoa<\/option><option  value=\"San Marino\">San Marino<\/option><option  value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\">Saudi Arabia<\/option><option  value=\"Senegal\">Senegal<\/option><option  value=\"Serbia and Montenegro\">Serbia and Montenegro<\/option><option  value=\"Seychelles\">Seychelles<\/option><option  value=\"Sierra Leone\">Sierra Leone<\/option><option  value=\"Singapore\">Singapore<\/option><option  value=\"Slovakia\">Slovakia<\/option><option  value=\"Slovenia\">Slovenia<\/option><option  value=\"Solomon Islands\">Solomon Islands<\/option><option  value=\"Somalia\">Somalia<\/option><option  value=\"South Africa\">South Africa<\/option><option  value=\"South Sudan\">South Sudan<\/option><option  value=\"Spain\">Spain<\/option><option  value=\"Sri Lanka\">Sri Lanka<\/option><option  value=\"Sudan\">Sudan<\/option><option  value=\"Suriname\">Suriname<\/option><option  value=\"Swaziland\">Swaziland<\/option><option  value=\"Sweden\">Sweden<\/option><option  value=\"Switzerland\">Switzerland<\/option><option  value=\"Syria\">Syria<\/option><option  value=\"Taiwan\">Taiwan<\/option><option  value=\"Tajikistan\">Tajikistan<\/option><option  value=\"Tanzania\">Tanzania<\/option><option  value=\"Thailand\">Thailand<\/option><option  value=\"Togo\">Togo<\/option><option  value=\"Tonga\">Tonga<\/option><option  value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option  value=\"Tunisia\">Tunisia<\/option><option  value=\"Turkey\">Turkey<\/option><option  value=\"Turkmenistan\">Turkmenistan<\/option><option  value=\"Tuvalu\">Tuvalu<\/option><option  value=\"Uganda\">Uganda<\/option><option  value=\"Ukraine\">Ukraine<\/option><option  value=\"United Arab Emirates\">United Arab Emirates<\/option><option  value=\"United Kingdom\">United Kingdom<\/option><option  value=\"United States\">United States<\/option><option  value=\"Uruguay\">Uruguay<\/option><option  value=\"Uzbekistan\">Uzbekistan<\/option><option  value=\"Vanuatu\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\">Venezuela<\/option><option  value=\"Vietnam\">Vietnam<\/option><option  value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option  value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option  value=\"Yemen\">Yemen<\/option><option  value=\"Zambia\">Zambia<\/option><option  value=\"Zimbabwe\">Zimbabwe<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_81_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_4znmn\" id=\"field_4znmn_label\" class=\"frm_primary_label\">Telephone Number (include area code)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_4znmn\" name=\"item_meta[81]\" value=\"\"  data-reqmsg=\"Telephone Number (include area code) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_22_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n    <label for=\"field_5zykn\" id=\"field_5zykn_label\" class=\"frm_primary_label\">Fax Number (include area code)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_5zykn\" name=\"item_meta[22]\" value=\"\"  data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_23_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full vertical_radio\">\r\n    <div  id=\"field_ph5z6_label\" class=\"frm_primary_label\"><b>Will the above person be the Primary Technical Contact?<\/b>\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_ph5z6_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-0\"><label for=\"field_ph5z6-0\"><input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_ph5z6-0\" value=\"Yes\"  data-reqmsg=\"&lt;b&gt;Will the above person be the Primary Technical Contact?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;Will the above person be the Primary Technical Contact?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-1\"><label for=\"field_ph5z6-1\"><input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_ph5z6-1\" value=\"No\"  data-reqmsg=\"&lt;b&gt;Will the above person be the Primary Technical Contact?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;Will the above person be the Primary Technical Contact?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   \/> No<\/label><\/div>\n<\/div>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_ph5z6\">Primary Technical Contact is 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.<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_32_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n    <label for=\"field_v2djs\" id=\"field_v2djs_label\" class=\"frm_primary_label\">If No, please enter the <b>Contact Name<\/b> of an appropriate Primary Technical Contact below:\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_v2djs\" name=\"item_meta[32]\" value=\"\"  data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_33_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n    <label for=\"field_2adqg\" id=\"field_2adqg_label\" class=\"frm_primary_label\">Email Address\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_2adqg\" name=\"item_meta[33]\" value=\"\"  data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_34_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n    <label for=\"field_dzpfg\" id=\"field_dzpfg_label\" class=\"frm_primary_label\">Position (Job Title)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_dzpfg\" name=\"item_meta[34]\" value=\"\"  data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_35_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_4224i\" id=\"field_4224i_label\" class=\"frm_primary_label\">Please nominate the <b> Contact Person<\/b> in your organisation who will have the <b>authority to approve FAST access to others.<\/b> \r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_4224i\" name=\"item_meta[35]\" value=\"\"  data-reqmsg=\"Please nominate the &lt;b&gt; Contact Person&lt;\/b&gt; in your organisation who will have the &lt;b&gt;authority to approve FAST access to others.&lt;\/b&gt;  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_4224i\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_4224i\">FAST is Resonance Health\u2019s 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.<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_36_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_1zwys\" id=\"field_1zwys_label\" class=\"frm_primary_label\">Email Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_1zwys\" name=\"item_meta[36]\" value=\"\"  data-reqmsg=\"Email Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_37_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_n5y36\" id=\"field_n5y36_label\" class=\"frm_primary_label\">Position (Job Title)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_n5y36\" name=\"item_meta[37]\" value=\"\"  data-reqmsg=\"Position (Job Title) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_38_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full vertical_radio\">\r\n    <div  id=\"field_c7156_label\" class=\"frm_primary_label\">Which service(s) would you like to set up for your organization?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_c7156_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_38-0\"><label for=\"field_c7156-0\"><input type=\"checkbox\" name=\"item_meta[38][]\" id=\"field_c7156-0\" value=\"FerriScan\u00ae analysis\"  data-reqmsg=\"Which service(s) would you like to set up for your organization? cannot be blank.\" data-invmsg=\"Which service(s) would you like to set up for your organization? is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> FerriScan\u00ae analysis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_38-1\"><label for=\"field_c7156-1\"><input type=\"checkbox\" name=\"item_meta[38][]\" id=\"field_c7156-1\" value=\"Cardiac T2* analysis\"  data-reqmsg=\"Which service(s) would you like to set up for your organization? cannot be blank.\" data-invmsg=\"Which service(s) would you like to set up for your organization? is invalid\" aria-invalid=\"false\"   \/> Cardiac T2* analysis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_38-2\"><label for=\"field_c7156-2\"><input type=\"checkbox\" name=\"item_meta[38][]\" id=\"field_c7156-2\" value=\"HepaFat-Scan\u00ae\"  data-reqmsg=\"Which service(s) would you like to set up for your organization? cannot be blank.\" data-invmsg=\"Which service(s) would you like to set up for your organization? is invalid\" aria-invalid=\"false\"   \/> HepaFat-Scan\u00ae<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_38-3\"><label for=\"field_c7156-3\"><input type=\"checkbox\" name=\"item_meta[38][]\" id=\"field_c7156-3\" value=\"Bone Marrow R2 analysis\"  data-reqmsg=\"Which service(s) would you like to set up for your organization? cannot be blank.\" data-invmsg=\"Which service(s) would you like to set up for your organization? is invalid\" aria-invalid=\"false\"   \/> Bone Marrow R2 analysis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_38-4\"><label for=\"field_c7156-4\"><input type=\"checkbox\" name=\"item_meta[38][]\" id=\"field_c7156-4\" value=\"Spleen R2* analysis\"  data-reqmsg=\"Which service(s) would you like to set up for your organization? cannot be blank.\" data-invmsg=\"Which service(s) would you like to set up for your organization? is invalid\" aria-invalid=\"false\"   \/> Spleen R2* analysis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_38-5\"><label for=\"field_c7156-5\"><input type=\"checkbox\" name=\"item_meta[38][]\" id=\"field_c7156-5\" value=\"Liver Volume analysis\"  data-reqmsg=\"Which service(s) would you like to set up for your organization? cannot be blank.\" data-invmsg=\"Which service(s) would you like to set up for your organization? is invalid\" aria-invalid=\"false\"   \/> Liver Volume analysis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_38-6\"><label for=\"field_c7156-6\"><input type=\"checkbox\" name=\"item_meta[38][]\" id=\"field_c7156-6\" value=\"Spleen Volume analysis\"  data-reqmsg=\"Which service(s) would you like to set up for your organization? cannot be blank.\" data-invmsg=\"Which service(s) would you like to set up for your organization? is invalid\" aria-invalid=\"false\"   \/> Spleen Volume analysis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_38-7\"><label for=\"field_c7156-7\"><input type=\"checkbox\" name=\"item_meta[38][]\" id=\"field_c7156-7\" value=\"Pancreatic Fat analysis\"  data-reqmsg=\"Which service(s) would you like to set up for your organization? cannot be blank.\" data-invmsg=\"Which service(s) would you like to set up for your organization? is invalid\" aria-invalid=\"false\"   \/> Pancreatic Fat analysis<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_39_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full vertical_radio\">\r\n    <div  id=\"field_97a36_label\" class=\"frm_primary_label\">What type of MRI Scanner will you use?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_97a36_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-0\"><label for=\"field_97a36-0\"><input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_97a36-0\" value=\"Siemens\"  data-reqmsg=\"What type of MRI Scanner will you use? cannot be blank.\" data-invmsg=\"What type of MRI Scanner will you use? is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> Siemens<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-1\"><label for=\"field_97a36-1\"><input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_97a36-1\" value=\"Philips\"  data-reqmsg=\"What type of MRI Scanner will you use? cannot be blank.\" data-invmsg=\"What type of MRI Scanner will you use? is invalid\" aria-invalid=\"false\"   \/> Philips<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-2\"><label for=\"field_97a36-2\"><input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_97a36-2\" value=\"GE\"  data-reqmsg=\"What type of MRI Scanner will you use? cannot be blank.\" data-invmsg=\"What type of MRI Scanner will you use? is invalid\" aria-invalid=\"false\"   \/> GE<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-3\"><label for=\"field_97a36-3\"><input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_97a36-3\" value=\"Other\"  data-reqmsg=\"What type of MRI Scanner will you use? cannot be blank.\" data-invmsg=\"What type of MRI Scanner will you use? is invalid\" aria-invalid=\"false\"   \/> Other<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_40_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n    <label for=\"field_95rvt\" id=\"field_95rvt_label\" class=\"frm_primary_label\">If &#8216;Other&#8217;, please specify manufacturer\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_95rvt\" name=\"item_meta[40]\" value=\"\"  data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_41_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_2z1y7\" id=\"field_2z1y7_label\" class=\"frm_primary_label\">Scanner Model?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_2z1y7\" name=\"item_meta[41]\" value=\"\"  data-reqmsg=\"Scanner Model? cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_42_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n    <label for=\"field_ugter\" id=\"field_ugter_label\" class=\"frm_primary_label\">Scanner Serial Number?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ugter\" name=\"item_meta[42]\" value=\"\"  data-reqmsg=\"Scanner Serial Number? cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_43_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_i23eo_label\" class=\"frm_primary_label\">Please confirm the field strength of your scanner\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_i23eo_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_43-0\"><label for=\"field_i23eo-0\"><input type=\"checkbox\" name=\"item_meta[43][]\" id=\"field_i23eo-0\" value=\"1.5T (All services, including FerriScan\u00ae, FerriSmart, Cardiac T2*, HepaFat-Scan, and all others)\"  data-reqmsg=\"Please confirm the field strength of your scanner cannot be blank.\" data-invmsg=\"Please confirm the field strength of your scanner is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> 1.5T (All services, including FerriScan\u00ae, FerriSmart, Cardiac T2*, HepaFat-Scan, and all others)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_43-1\"><label for=\"field_i23eo-1\"><input type=\"checkbox\" name=\"item_meta[43][]\" id=\"field_i23eo-1\" value=\"3T (Currently ONLY available for FerriScan and HepaFat-Scan)\"  data-reqmsg=\"Please confirm the field strength of your scanner cannot be blank.\" data-invmsg=\"Please confirm the field strength of your scanner is invalid\" aria-invalid=\"false\"   \/> 3T (Currently ONLY available for FerriScan and HepaFat-Scan)<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_44_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_frnna_label\" class=\"frm_primary_label\">Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_frnna_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_44-0\"><label for=\"field_frnna-0\"><input type=\"checkbox\" name=\"item_meta[44][]\" id=\"field_frnna-0\" value=\"Yes\"  data-reqmsg=\"Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence? cannot be blank.\" data-invmsg=\"Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence? is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_44-1\"><label for=\"field_frnna-1\"><input type=\"checkbox\" name=\"item_meta[44][]\" id=\"field_frnna-1\" value=\"No\"  data-reqmsg=\"Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence? cannot be blank.\" data-invmsg=\"Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence? is invalid\" aria-invalid=\"false\"   \/> No<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_44-2\"><label for=\"field_frnna-2\"><input type=\"checkbox\" name=\"item_meta[44][]\" id=\"field_frnna-2\" value=\"Unsure\"  data-reqmsg=\"Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence? cannot be blank.\" data-invmsg=\"Can your scanner achieve a minimum TE of 6.0ms with a T2-weighted single spin echo (SE) sequence? is invalid\" aria-invalid=\"false\"   \/> Unsure<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_45_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_uqy42_label\" class=\"frm_primary_label\">Do you have a current Service Contract with your MRI manufacturer for regular maintenance?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_uqy42_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_45-0\"><label for=\"field_uqy42-0\"><input type=\"checkbox\" name=\"item_meta[45][]\" id=\"field_uqy42-0\" value=\"Yes\"  data-reqmsg=\"Do you have a current Service Contract with your MRI manufacturer for regular maintenance? cannot be blank.\" data-invmsg=\"Do you have a current Service Contract with your MRI manufacturer for regular maintenance? is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_45-1\"><label for=\"field_uqy42-1\"><input type=\"checkbox\" name=\"item_meta[45][]\" id=\"field_uqy42-1\" value=\"No\"  data-reqmsg=\"Do you have a current Service Contract with your MRI manufacturer for regular maintenance? cannot be blank.\" data-invmsg=\"Do you have a current Service Contract with your MRI manufacturer for regular maintenance? is invalid\" aria-invalid=\"false\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_46_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_14ewz_label\" class=\"frm_primary_label\"><b>Cardiac T2* only<\/b> &#8211; Is your scanner equipped with an ECG facility and a cardiac package with a multi-echo T2* sequence?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_14ewz_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_46-0\"><label for=\"field_14ewz-0\"><input type=\"checkbox\" name=\"item_meta[46][]\" id=\"field_14ewz-0\" value=\"Yes\"  data-invmsg=\"&lt;b&gt;Cardiac T2* only&lt;\/b&gt; - Is your scanner equipped with an ECG facility and a cardiac package with a multi-echo T2* sequence? is invalid\" aria-invalid=\"false\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_46-1\"><label for=\"field_14ewz-1\"><input type=\"checkbox\" name=\"item_meta[46][]\" id=\"field_14ewz-1\" value=\"No\"  data-invmsg=\"&lt;b&gt;Cardiac T2* only&lt;\/b&gt; - Is your scanner equipped with an ECG facility and a cardiac package with a multi-echo T2* sequence? is invalid\" aria-invalid=\"false\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_47_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_1zapv_label\" class=\"frm_primary_label\"><b>Cardiac T2* only<\/b> &#8211; Is your scanner able to achieve a minimum TE \u2264 3ms (1st TE) and a maximum TE \u2265 16ms (8th TE) with a multi-echo gradient echo sequence?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_1zapv_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_47-0\"><label for=\"field_1zapv-0\"><input type=\"checkbox\" name=\"item_meta[47][]\" id=\"field_1zapv-0\" value=\"Yes\"  data-invmsg=\"&lt;b&gt;Cardiac T2* only&lt;\/b&gt; - Is your scanner able to achieve a minimum TE \u2264 3ms (1st TE) and a maximum TE \u2265 16ms (8th TE) with a multi-echo gradient echo sequence? is invalid\" aria-invalid=\"false\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_47-1\"><label for=\"field_1zapv-1\"><input type=\"checkbox\" name=\"item_meta[47][]\" id=\"field_1zapv-1\" value=\"No\"  data-invmsg=\"&lt;b&gt;Cardiac T2* only&lt;\/b&gt; - Is your scanner able to achieve a minimum TE \u2264 3ms (1st TE) and a maximum TE \u2265 16ms (8th TE) with a multi-echo gradient echo sequence? is invalid\" aria-invalid=\"false\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_49_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_p89vi_label\" class=\"frm_primary_label\"><b>How would the cost of the service(s) be funded at your centre?<\/b> (tick any that apply)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_p89vi_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_49-0\"><label for=\"field_p89vi-0\"><input type=\"checkbox\" name=\"item_meta[49][]\" id=\"field_p89vi-0\" value=\"Covered by the MRI Department\"  data-reqmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) cannot be blank.\" data-invmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> Covered by the MRI Department<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_49-1\"><label for=\"field_p89vi-1\"><input type=\"checkbox\" name=\"item_meta[49][]\" id=\"field_p89vi-1\" value=\"Covered by Government reimbursement\"  data-reqmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) cannot be blank.\" data-invmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) is invalid\" aria-invalid=\"false\"   \/> Covered by Government reimbursement<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_49-2\"><label for=\"field_p89vi-2\"><input type=\"checkbox\" name=\"item_meta[49][]\" id=\"field_p89vi-2\" value=\"Charged to department \/ referring clinician\"  data-reqmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) cannot be blank.\" data-invmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) is invalid\" aria-invalid=\"false\"   \/> Charged to department \/ referring clinician<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_49-3\"><label for=\"field_p89vi-3\"><input type=\"checkbox\" name=\"item_meta[49][]\" id=\"field_p89vi-3\" value=\"Charged to a Pharmaceutical company\"  data-reqmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) cannot be blank.\" data-invmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) is invalid\" aria-invalid=\"false\"   \/> Charged to a Pharmaceutical company<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_49-4\"><label for=\"field_p89vi-4\"><input type=\"checkbox\" name=\"item_meta[49][]\" id=\"field_p89vi-4\" value=\"Charged directly to the patient\"  data-reqmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) cannot be blank.\" data-invmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) is invalid\" aria-invalid=\"false\"   \/> Charged directly to the patient<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_49-6\"><label for=\"field_p89vi-6\"><input type=\"checkbox\" name=\"item_meta[49][]\" id=\"field_p89vi-6\" value=\"Other\"  data-reqmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) cannot be blank.\" data-invmsg=\"&lt;b&gt;How would the cost of the service(s) be funded at your centre?&lt;\/b&gt; (tick any that apply) is invalid\" aria-invalid=\"false\"   \/> Other<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_48_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_tbovj_label\" class=\"frm_primary_label\"><b>How did you hear about Resonance Health?<\/b>\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_tbovj_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-0\"><label for=\"field_tbovj-0\"><input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_tbovj-0\" value=\"Referring clinician request\"  data-reqmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> Referring clinician request<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-1\"><label for=\"field_tbovj-1\"><input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_tbovj-1\" value=\"Conference attendance\"  data-reqmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   \/> Conference attendance<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-2\"><label for=\"field_tbovj-2\"><input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_tbovj-2\" value=\"Publications\"  data-reqmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   \/> Publications<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-3\"><label for=\"field_tbovj-3\"><input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_tbovj-3\" value=\"Personal Research\"  data-reqmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   \/> Personal Research<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-4\"><label for=\"field_tbovj-4\"><input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_tbovj-4\" value=\"Direct contact from Resonance Health\"  data-reqmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   \/> Direct contact from Resonance Health<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-5\"><label for=\"field_tbovj-5\"><input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_tbovj-5\" value=\"Previously involved in a clinical trial\"  data-reqmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   \/> Previously involved in a clinical trial<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-6\"><label for=\"field_tbovj-6\"><input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_tbovj-6\" value=\"Other\"  data-reqmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; cannot be blank.\" data-invmsg=\"&lt;b&gt;How did you hear about Resonance Health?&lt;\/b&gt; is invalid\" aria-invalid=\"false\"   \/> Other<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_84_container\" class=\"frm_form_field form-field  frm_none_container\">\n    <div  id=\"field_vf3ir_label\" class=\"frm_primary_label\">reCAPTCHA\n        <span class=\"frm_required\"><\/span>\n    <\/div>\n    <div id=\"field_vf3ir\" class=\"frm-g-recaptcha\" data-sitekey=\"6LetzMQUAAAAAPTyAuC5Abk4S8qfwLAZcFaxzNAP\" data-size=\"normal\" data-theme=\"light\"><\/div>\n    \n    \n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t\t<div class=\"frm__6526bf0916965\">\n\t\t\t\t<label for=\"frm_email_2\" >\n\t\t\t\t\tIf you are human, leave this field blank.\t\t\t\t<\/label>\n\t\t\t\t<input  id=\"frm_email_2\" type=\"text\" class=\"frm_verify\" name=\"frm__6526bf0916965\" value=\"\" autocomplete=\"false\"  \/>\n\t\t\t<\/div>\n\t\t<div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n<\/form>\n<\/div>\n<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>MRI Scanner Details Form<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_acf_changed":false,"footnotes":""},"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.2 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>MRI Scanner Details Form<\/title>\n<meta name=\"description\" content=\"Register your interest in FerriScan and our other iron services. FerriScan is a system for quantifying liver iron concentration (LIC) from specially acquired MRI images.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/ferriscan.com\/mri-scanner-details-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"FerriScan - Scanner Details Form\" \/>\n<meta property=\"og:description\" content=\"Register your interest in FerriScan and our other iron services. FerriScan is a system for quantifying liver iron concentration (LIC) from specially acquired MRI images.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/ferriscan.com\/mri-scanner-details-form\/\" \/>\n<meta property=\"og:site_name\" content=\"FerriScan\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/ResonanceHealthLtd\/\" \/>\n<meta property=\"article:modified_time\" content=\"2020-05-01T00:30:11+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/ferriscan.com\/wp-content\/uploads\/2019\/09\/ferriscanreport-medical-1024x512.png\" \/>\n\t<meta property=\"og:image:width\" content=\"1024\" \/>\n\t<meta property=\"og:image:height\" content=\"512\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/png\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:title\" content=\"FerriScan - Scanner Details Form\" \/>\n<meta name=\"twitter:description\" content=\"Register your interest in FerriScan and our other iron services. 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