Forms

forms

  Computed Tomography Research Forms and Documents:

v CT Request for Use (must be completed first)

v CT Confirmation and Charge Form

v CT Contrast Consent Form

  Magnetic Resonance Imaging Core (MRIC) Forms and Documents:

v  MRI Request for Scan Time (Funded Study/Pilot Study)

v MRI Charge Form

v MRI Contrast Consent Form

  MicroCT and Toshiba CT (at A1 Building) Forms and Documents:

v Downtown Imaging – Request for Scan Time

v Downtown Imaging Charge Form

  MicroMR 7.0T Forms and Documents:

v MicroMR Request for Scan Time

v MicroMR Charge Form

  Positron Emission Tomography Center (PET) Forms and Documents:

v PET Request for Scan Time (human)

v PET Request for Scan Time (animal)

v PET Request for Pilot Study

    Imaging Informatics Forms and Documents:

v TeraRecon Servers and Workstations – Request for Research Access

v To obtain scan rates (for CT, MRI, MicroCT, Toshiba CT, and 7T), please call Beverly Gordon (716-3622)

v To obtain scan rates for PET, please call Kim Black (716-5625) or Dr. Pradeep Garg (716-5624).

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Winston-Salem, NC 27157

The information on this Website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified healthcare provider. If you have a medical problem or a health-related question, consult your physician or call Health On-Call at 336-716-2255 or 1-800-446-2255.

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	Last Modified: 7/14/2009