Gamma Camera Form:

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

Head Count Single, Dual, Triple?


List Collimators Included:
Collimators Carts:
Exchanger

System
Thickness of Crystals:
Detector Size   x 

 When? 

Computer Information:

Comp Platform Type:
DOM
SW Type
SW Level

Monitor
If yes,
If yes,
If yes,
If yes,

Other Equipment:
  • 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: