UCLA Brain Mapping Center

Scan Date: *
format: 03/27/14. Check the PET calendar for available day/time.

Time: *
:

Duration: *

:

Subject ID#: *
No initials or medical record numbers

Scan #: *

Gender: *

Principal Investigator: *

IRB/ARC #: *

Radiopharmaceutical: *

Is this scan quantitative: *
Are there blood draws during the scan acquisition?
No
Yes

Please note any special instructions or comments here:

Request Submitted By: *

Email: *

Is this an RDRC Protocol? (i.e. O15)
Yes