Imaging Request Form

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This Imaging Request is mainly for scheduling staff-supported imaging studies. For user-operated imaging studies, trained users can schedule your own studies on the corresponding online calendars. For any questions or problems, please send email to: bricsai@med.unc.edu, or call 966-2855.

Requester Name: *

Requester Email: *

PI Name (Last, First) *

Billing Information *

UNC user (enter billing information below)

Non-UNC user (enter your institution name below)

Provide UNC Chart Fields Information, including Business Unit, Fund code, Source code, Department code, and any additional fields (PC Bus Unit, Project ID, Activity code, Program code, Cost code code, etc.) *

For Example: UNCCH; 21144; 13001; 426001

For outside UNC investigators, please provide your billing contact information, and address:

Imaging systems to be used: *

9.4T MRI Scanner

PET-CT (GE eXplore)

SPECT-CT(GE speCZT)

CT (GE CT-120)

CT (CNT-CT mouse only)

Specimen-CT (SCANCO uCT40)

Ultrasound (Vevo 2100)

Optical imaging

DEXA

Staff Support Only

Required

Imaging Subject:

Please select one, and list quantity below

Live Animal (please make sure you have approved IACUC protocol)

Specimen

Clear selection

Quantity: *

Number of animals or specimens

Desired date: *

Example: 01/01/2013

Desired starting time: *

Example: 10:00AM

Other notes:

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