CT Form:

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

Slice
Slice Time:

Generator: Model: kW: mA: kV:

Computer: Model: DOM: SW Rev:
Archiving Other:

Application Platform:

WorkStation1: Rev:
WorkStation2:  Rev:
Satellite Console:

Gantry Model:  Detector Type:
Slice Count  Scan Seconds:  as of:

Tube Model:  DOM:  MHU:
Slice Count:  Scan Seconds:  as of:
Tube Install Date:  Housing Type:

Permanatly Installed Software Options:

Option: Option:
Option: Option:
Option: Option:
Option: Option:
Option: Option:
Option: Option:
Option: Option:
Option: Option:
Option: Option:
Option: Option:
Option:

Radiation Protection Type:
Chiller System:
UPS:
Power Regulation Device:
  • 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: