Janey Briscoe Center for Cardiovascular Research

Request For C-Arm Use Please fill out the top portion of this form and electronically submit it to either G Patricia Escobar D.V.M. ([email protected] ). Please fill out prior to c-arm use and return to us. Thank You.

Date Requested: Date of Procedure Time of Procedure ______

Is this a UT Funded Project? □ Yes □ No If Yes PID# ______If No, Billing Address: ______Fund# ______Dept ID# ______Contact Name: ______

Investigator/Company Name:

What will the c-arm be used for? .

What is the estimated time needed?

Will there be images that you need stored or pulled off the c-arm for your records? □ Yes □ No (Please be aware that there may be an additional fee for saved images or images that we transfer for you)

Contact Name: Contact Number: .

Janey Briscoe Rep Approval Signature: ______Approval Date: ____/____/____

Invoice ID Number Actual C-Arm Use

Please fill this section out during actual use of C-arm and return to G Patricia Escobar DVM.

Actual time use of C-arm: ______Start:______End______

Representative Time: ______Arrive:______Left:______

Number of Images saved: ______Number of Images Requiring Transfer to cd: ______

Notes:______

Signature: ______Date: ___/___/___