Radiology OneSource

DR/X-Ray/RF/Remote/Multi-purpose 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

Remote

Generator

Model:

kW:

mA:

kV:

Single Phase

Three Phase

High Frequency

Anatomical Programming

X-ray Tube Model:

DOM:

Focal Spots:

Tube Crane Model		Overhead	Floor mounted	Floor-wall	Floor-ceiling	Table Integrated
Collimator		Manual	Semi-Auto	Automatic

Tomo

Model:

Wall Unit	Cassette Stand
	Bucky	Tilt	Photo Timed

DR/RF/Remote/Multi-Purp.

Flat Panel Detector

Model:

Size:

X-ray Tube

Model:

DOM:

Focal Spots:

Image Intensifier

Model:

Size of II:

DOM:

Spot Film Device

Model:

Size:

Digital

Monitor

Cart

Suspended

Cut Film Camera

Model:

Table

Model:

Fixed Height

Elevations

Float	None	2-Way	4-Way
Tilt	90/15	90/30	90/45	90/90

Digital System:

Model:

SW Rev Level:

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:	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: