McConnell Brain Imaging Centre Scan Request Form

Account Information
Do you have a McGill FOAPAL Number? *
"Yes" will display fields for more information

Please enter FOAPAL#:

Name of FOAPAL Holder:

Telephone Number of FOAPAL Holder:

Ext#

Please see the Online Schedule for available times.

Protocol:

Ethics Number:

*
( Alphanumeric characters or dash only)

Equipment Required:
If tracer needed, it MUST be entered in the
"tracer & other pertinent information" section

Dates Requested

1^st Choice:
(Click on field to clear)

Please use date picker

2^nd Choice:
(Click on field to clear)

3^rd Choice:
(Click on field to clear)

Start Time:

: *

Multiple Subjects?

How many Subjects?

End Time:

: *

Tracer & other pertinent information or instructions relative to this study.

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