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MRI 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
Magnet Name:
Type
Permanent
Resistive
Super-conductive
Single Cryo
Dual Cryo
Magnet Design
Short Bore
Medium Bore
Long Bore
Open
Config/if upgrade
Originial
Upgrade
Install Date:
Shielding
Active
Passive
External Magnetic
Mini
Full
Field Strength
0.2T-0.7T
0.5T
1.0T
1.5T
3.0T
Other:
Helium Level
Last Fill:
Last Cold Head Replacement:
Gradient Strength
Slew Rate:
Gradient overdrive
Software Level:
Computer
Platform:
Permanatly Installed Software Options:
3D
Option:
Angio
Option:
Bolus
Option:
Breast
Option:
Cardiac
Option:
Core
Option:
EPI
Option:
FSE
Option:
MRA
Option:
Neuro
Option:
Perfusion
Option:
Phased Array
Option:
Spectroscopy
Option:
Turbo
Option:
Other
Option:
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.
Coil 1
Linear
Phased Array
Quadretuee
Needs Repair
Coil 2
Linear
Phased Array
Quadretuee
Needs Repair
Coil 3
Linear
Phased Array
Quadretuee
Needs Repair
Coil 4
Linear
Phased Array
Quadretuee
Needs Repair
Coil 5
Linear
Phased Array
Quadretuee
Needs Repair
Coil 6
Linear
Phased Array
Quadretuee
Needs Repair
Coil 7
Linear
Phased Array
Quadretuee
Needs Repair
Coil 8
Linear
Phased Array
Quadretuee
Needs Repair
Coil 9
Linear
Phased Array
Quadretuee
Needs Repair
Coil 10
Linear
Phased Array
Quadretuee
Needs Repair
Additonal Workstation
Included w/System
Type:
Satellite Console
Included w/System
Type:
Chiller
Included w/System
Type:
RF Shield
Included w/System
Type:
Power Regulator
Included w/System
Type:
Laser/Imager
Included w/System
Type:
Patient Monitor
Included w/System
Type:
Injector
Included w/System
Type:
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:
