If the scan involves a series of images, please specify series to be used:
Examples: chest-PA + lateral, spine-lumbar spine series
Total # of Scans (per patient) to be performed for research Enter N/A for # of scans if end point not known and indicate frequency below
Total # of Scans (per patient) to be performed for research Enter N/A for # of scans if end point not known and indicate frequency below
Total # of Scans (per patient) to be performed for research Enter N/A for # of scans if end point not known and indicate frequency below
Additional Comments If trial does not have a clear end point, please specify what determines end of treatment. Also comment on what additional X-ray and/or Nuclear Medicine based scans subjects will receive as standard of care.
Billing (PTAO# Required)* For each trial submitted, the HIRE Committee now assesses a one-time charge of $350 to cover the hospital staff cost of dose calculation and the creation of consent language. If you submit both X-ray AND Nuclear Medicine forms, you will only be charged once. PLEASE ENTER PTAO# BELOW:
