Radiology OneSource

Phone: +1 615-577-1RAD(1723)
Fax: +1 615-577-1122
Email: Info@radiologyonesource.com

Cardiac/Angio Form

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 Settings50Hz 60Hz		Application Cath Angio

Stand Model:

_______________________________

Mount:

Ceiling

Floor

Table Model:

_______________________________

Stepper

Generator Model:

_______________________________

kW:_________

mA:_________

kV:_________

Injector

Model:_______________________________

DOM:____________

Mounted

Ceiling

Pedistal

Positioner

Digital System

Model:_______________________________

Revision Level:

____________

DICOM

Option:_______________________________

Single Plane
Image Intensifier	Model:_____________________________	Size of II:_________	DOM:_________

Bi-Plane	Lateral Type:_______________________________
Image Intensifier	Model:_______________________________	Size of II:_________	DOM:_________

Age of Glass	____________	X-Ray Tube Type:_______________________________
Insert Age	____________

Cine Camera	Film Changer
TV Monitors	Monitor
Archive Capable:	CD DICOM Other:_______________________________
Shielding
VCR

NIU

Workstation 1:	_____________________
Workstation 2:	_____________________
Other:	_____________________

Patient Monitor

Included w/System

Yes

Type:_____________________

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:	_______________________________