Radiology OneSource
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MRI Form
Manufacturer Model Production Year
S/N SiteID Available Date
SW Rev Current Settings

Magnet Name
Type
Magnet Design
Config/if upgrade Install Date:

Shielding

Field Strength

Helium Level

Gradient Strength Slew Rate:
Gradient overdrive Software Level:
Computer Platform:

Permanatly Installed Software Options:

Coil 1
Coil 2
Coil 3
Coil 4
Coil 5
Coil 6
Coil 7
Coil 8
Coil 9
Coil 10

Additonal Workstation Included w/System
Satellite Console Included w/System
Chiller Included w/System
RF Shield Included w/System
Power Regulator Included w/System
Laser/Imager Included w/System
Patient Monitor Included w/System
Injector Included w/System

This installation is:
System is:
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:
Site Info
Company/Entity:
* Name/Rep: *
* Email: *
Phone:
Deal Status:
Address:
Address (cont.)
City: State:
Province: Country:
Zip Code: