CT/MRI Scan Posting Notification Form

Patient Trial Number (3-digit)

Patient Initials (If known)

4-digit Scan Transfer Code

MRI

Both CT and MRI

Diagnostic Staging

Response to CRT

Date of Diagnostic Staging CT Scan (If applicable)

Date of Diagnostic Staging MRI Scan (If applicable)

Date of Response to CRT CT Scan (If applicable)

Date of Response to CRT MRI Scan (If applicable)

Anonymised Scan/s

An Anonymised Patient Scan Transfer Form

Date Posted

Streetwise Couriers

CitySprint Couriers

Royal Mail Recorded Delivery

Other, please specify in comments field

Comments (Optional)

Name of Local PET-Neck Contact

E-mail Address of Local PET-Neck Contact

Date Form Completed

Privacy notice

The data provided is used solely for the PET-Neck trial

The University of Warwick is the Data Controller of any information you have entered on this form and is committed to protecting the rights of individuals in line with Data Protection Legislation. The University's Data Protection webpages provide further information on your rights and how the University processes personal data. If you wish to submit a data subjects rights request, make a complaint or report a suspected personal data breach, please contact the University’s Data Protection Officer by email at infocompliance@warwick.ac.uk.

Clinical Trials Unit

CT/MRI Scan Posting Notification Form

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