Mammography Form:

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

Tube Type: Exposure Count:
Housing: Focal Spots: 

Compression

SID

Phototiming:

Number of Paddles Compression: Spot: Magnification:
Biopsy: Other:
Number of Apertures:

Bucky



Stereotactic upright device model:

Prone Table Model:
Tube Type: Exposure Count:
Housing Focal Spots: 
  • 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: