Please complete the following form to request echocardiogram/ultrasound exams. Please check each option that applies to your study in the boxes that appear below. Note that multiple options may apply. Hold Ctrl key and click to choose multiple options in each box if necessary.
Upon submission, the Core Technical Director will contact you to arrange scanning dates.
*All fields marked with the asterisk are required prior to submitting. Please type n/a if leaving one field blank.
Basic Echocardiography Requested* Hold Ctrl key and click to choose multiple options
*The Principal Investigator understands the fees for services and agrees to pay for the services requested*
I have reviewed the scheduled fees and agree to pay for the services requested*