Miscellaneous Image Review Request

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Please complete the survey below.

This request form does not replace the Radiology Cost Estimate form; if tumor assessment reads are required, you must also complete the Radiology Cost Estimate Request.

Thank you!

Date of Request:

* must provide value

M-D-Y

Research Study/IRB #:

* must provide value

Abbreviated study title

P.I.:

* must provide value

PI email:

Choose which type of Radiology read you require

Non-diagnostic images

Specialized Read /Other

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Other: Specialized Read.

Please provide details of required read

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SPECIALIZED READ:

Is a Form to be completed by the Radiologist for the specialized study read? Choose Yes/ No

Note: * Charges may apply

* these charges are separate from the Tumor Assessment Read charges that should be on Finalized Radiology Cost Estimate. Reach out to Radiology Cost Estimate Manager if this was not on the Finalized Cost Estimate.

Yes

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Name of Form to be completed

Please attach form to be completed by the Radiologist.
You must pre-fill all subject/ study related fields; only the specialized read fields will be completed by the Radiologist

Upload file

Detail any special instructions for form completion

Scan Modality:

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Provide details for SCAN-Other:

Subject ID:

* must provide value

Scan Date:

* must provide value

M-D-Y

NON-DIAGNOSTIC READ:

Provide any additional information regarding the required read

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Provide email address of research coordinator who will receive the report

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(Option) Please type in a alternative email address which will receive the report:

Additional Comments:

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