Scan Review Request Form
This form is used to request a review of your participant's scan by the CFMI Medical Director (Dr. Turkeltaub). Please do not reveal your concerns to your participant until after the review is complete. We are are researchers not MDs. Dr. Turkeltaub will let you (and us) know whether there is anything that warrants further followup with the participant at which point the PI from your lab will contact the participant and Dr. Turkeltaub will be available to answer questions.

Please do not enter any PHI (Protected Health Information) such as name, date of birth, etc.
Sign in to Google to save your progress. Learn more
Your Name *
Your Email *
Your Lab/PI *
Subject ID *
Date of Scan *
MM
/
DD
/
YYYY
Subject Age *
Subject Dx (i.e., healthy control or someone with a diagnosis) *
Describe the nature and area of concern; include information about location (hemisphere, lobe, etc.) and on which scan(s) is it noticeable (MPRAGE, etc.). *
Please provide any other information that might be relevant (e.g., participant was complaining of a headache the day of the scan, has trouble walking or talking, etc.). Also, has the participant complained of any symptoms such as headache, changes in vision, hearing, or sensation, changes in coordination or movement, changes in speech, memory, or thinking.
Medical Director - Assessment regarding any findings.
Medical Director - Recommend course of action
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Georgetown University. Report Abuse
Google Forms