PET/CT Imaging Request
Submit this form to request microPET / microCT imaging or probe request at Crump. We will confirm the reservation in a timely manner via your e-mail provided, usually in a day or so. Please make every effort to consolidate in vitro probe requests with other requests.
User Full Name *
Your answer
Principal Investigator (must match Recharge ID) *
Your answer
Recharge ID *
e.g. AB2J
Your answer
ARC # *
e.g. 2014-123
Radiation LA # *
e.g. LA123
e.g. 12.24.0-f
Contact E-mail *
Your answer
Phone # or Ext *
Your answer
Study Details
Date of Study *
Time (start) *
Time (end) *
Animal or Object to be Scanned (select all that apply) *
Type of Scan (check all that apply)
PET scanner (if more than one, describe details in Comments section below)
If "other" above, indicate PET probe/isotope
Your answer
Number of PET scans *
Your answer
CT scanner (if more than one, describe details in Comments section below)
Number of CT scans *
Your answer
CT contrast agent
User provides, or will be recharged by Imaging Center if available.
Additional instructions or comments for staff?
e.g. Animals injected with toxin - will be handled by users only.
Your answer
If you'd like to duplicate this EXACT study request, please enter additional date(s) AND start time(s) below. Otherwise, please submit a new request.
e.g. 3/31/2015 at 1PM; 4/2/2015 at 1PM
Your answer
For non-UCLA Users:
Company/Institute Name
Your answer
Project ID
e.g. COM12 or COM12-025
Your answer
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