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DR/X-Ray/RF/Remote/Multi-purpose Form
I would like to
purchase
a system with the following specifications or...
I would like to
sell
a system with the following specifications.
Manufacturer
Model
Production Year
S/N
SiteID
Available Date
SW Rev
Current Settings
50Hz
60Hz
DR
XR
RF
Remote
MP
Generator
Model:
kW:
mA:
kV:
Single Phase
Three Phase
High Frequency
Anatomical Programming
X-ray Tube Model:
DOM:
Focal Spots:
Tube Crane Model
Overhead
Floor mounted
Floor-wall
Floor-ceiling
Table Integrated
Collimator
Manual
Semi-Auto
Automatic
Tomo
No
Yes
Model:
Wall Unit
Cassette Stand
Bucky
If Bucky, tilt?
Yes
No
Photo Timed
Yes
No
DR/RF/Remote/Multi-Purp.
Flat Panel Detector
Model:
Size:
X-ray Tube
Model:
DOM:
Focal Spots:
Image Intensifier
Model:
Size of II:
DOM:
Spot Film Device
Model:
Size:
Digital
Monitor
Cart
Suspended
Cut Film Camera
Model:
Table
Model:
Fixed Height
Elevations
Float
None
2-Way
4-Way
Tilt
90/15
90/30
90/45
90/90
Digital System:
Model:
SW Rev Level:
Other Equipment:
All System software and service codes must be on site and provided at time of removal.
All system manuals (operator and technical) must be on site and provided at the time of removal.
All service records must be on site and provided at the time of removal.
All phantoms must be on site and provided at the time of removal.
This installation is:
fixed
mobile
System is:
owned by facility
financed (owned by finance company/bank)
System Details
System is in good working condition and not in need of repair?
System is under service contract
No
Yes
with:
Location in facility (room number)
on floor
Loading dock is available?
System being replaced by:
Notes:
Site Info
Company/Entity:
*
Name/Rep:
*
*
Email:
*
Phone:
Deal Status:
Address:
Address (cont.)
City:
State:
Province:
Country:
Zip Code:
