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Ultrasound 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
Display
Color
B/W
Doppler
OB Calcs
Vascular
Cardiac
Harmonics
DICOM
Other Software:
VCR
Printer
Other Peripherals:
Transducers
1
Model:
Frequency:
Description:
2
Model:
Frequency:
Description:
3
Model:
Frequency:
Description:
4
Model:
Frequency:
Description:
5
Model:
Frequency:
Description:
6
Model:
Frequency:
Description:
7
Model:
Frequency:
Description:
8
Model:
Frequency:
Description:
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:
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:
