PET schedule request form – MRI / PET / TMS Operations

PLEASE READ THE FOLLOWING DOCUMENT SAFETY AND COVID-19 GUIDELINES BEFORE FILLING OUT THIS FORM.

If you need to cancel a PET slot please use the PET Schedule Cancellation Form.

Requester Email *

PI Name *

Account code *

Tracer Name *

Open Slot Date(s) Preference

Participant Time constraints *

Bay 6 or 7 *

Total Time in Scanner *

Injection Occurs in Bay? (dynamic) *

TOI *

Setup Begins *

Scan Begins: (put N/A if it's injecting inside the bay) *

Scan Ends *

Cleanup Ends *

Subject name or ID number *

This name will be matched with a list at the security desk for access into the building

IRB/SRAC/IACUC number: *

RDRC or IND *

if IND, please provide IND number

A-Line *

Plasma protein binding assay *

Additional Comments

COVID-19 Attestation *