<p> Janey Briscoe Center for Cardiovascular Research</p><p>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.</p><p>Date Requested: Date of Procedure Time of Procedure ______</p><p>Is this a UT Funded Project? □ Yes □ No If Yes PID# ______If No, Billing Address: ______Fund# ______Dept ID# ______Contact Name: ______</p><p>Investigator/Company Name: </p><p>What will the c-arm be used for? . </p><p>What is the estimated time needed? </p><p>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)</p><p>Contact Name: Contact Number: .</p><p>Janey Briscoe Rep Approval Signature: ______Approval Date: ____/____/____</p><p>Invoice ID Number Actual C-Arm Use</p><p>Please fill this section out during actual use of C-arm and return to G Patricia Escobar DVM.</p><p>Actual time use of C-arm: ______Start:______End______</p><p>Representative Time: ______Arrive:______Left:______</p><p>Number of Images saved: ______Number of Images Requiring Transfer to cd: ______</p><p>Notes:______</p><p>Signature: ______Date: ___/___/___</p>