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Cardiac/Angio 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
Application
Cath
Angio
Stand Model:
Mount:
Ceiling
Floor
Table Model:
Stepper:
Yes
No
Generator Model:
kW:
mA:
kV:
Injector:
No
Yes
If yes:
Model:
DOM:
Mounted
Ceiling
Pedistal
Positioner
Digital System
Model:
Revision Level:
DICOM
Option:
Single Plane
Image Intensifier
Model:
Size of II:
DOM:
Bi-Plane
Lateral Type:
Image Intensifier
Model:
Size of II:
DOM:
Age of Glass
X-Ray Tube Type:
Insert Age
Cine Camera
Yes
No
Film Changer
Yes
No
TV Monitors
Yes
No
Monitor:
Suspended
On Cart
Archive Capable:
CD
DICOM
Other:
Shielding:
Yes
No
VCR:
Yes
No
NIU
Yes
No
Workstation 1:
Workstation 2:
Other:
Patient Monitor
Yes
No
Included w/System
Yes
No
Type:
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:
