Cardiac/Angio Form:

Manufacturer Model Production Year
S/N SiteID Available Date
SW Rev Current Settings Application

Stand Model: Mount:

Table Model:

Generator Model: kW: mA: kV:

Model: DOM:

Digital System Model: Revision Level:

Option:

Image Intensifier Model: Size of II: DOM:

Image Intensifier Model: Size of II: DOM:

Age of Glass X-Ray Tube Type:
Insert Age

 Monitor:

Archive Capable:  Other:


Workstation 1:
Workstation 2:
Other:

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:
System is:

System Details

System is in good working condition and not in need of repair?
   with:
Location in facility (room number)   on floor 
Loading dock is available? 
System being replaced by: 

Site Info

Company/Entity:
* Name/Rep: *
* Email: *
Phone:
Deal Status:
Address:
Address (cont.)
City:
State/Province:
Country:
Zip Code: