C-ARM Form:

Manufacturer: Model: Production Year:
S/N: SiteID: Available Date:
SW Rev: Current Settings: Hours on System:

Generator
Fluoro Boost

Computer
Archiving Other:

Image Storage Capacity:

Application Platform

Tube Model: DOM: MHU:
Image Intensifier Model: Size of II: DOM:

Number of Monitors: Type: Line Rate:

Permanatly Installed Software Options:

Option: FPS:
Option: FPS:
Option: FPS:
Option: FPS:
  • 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: