Radiology OneSource

Cardiac/Angio Form:

Printable Version
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

Generator Model:

kW:

mA:

kV:

Injector

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

Film Changer

VCR

Shielding

TV Monitors

Monitor: Suspended On Cart

Archive Capable:

CD DICOM Other:

NIU

Workstation 1:
Workstation 2:
Other:

Patient Monitor

Included w/System

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.

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: