Radiology OneSource

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

C-ARM 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 Settings 50Hz 60Hz		Hours on System	____________

Generator Model:

_____________________

kW:_____________

mA:_____________

kV:_____________

Fluoro Boost Model:

_____________________

mA:_____________

kV:_____________

Computer Model:

_____________________

DOM: _____________

SW Rev: _____________

Archiving

DICOM

MATRIX

Other:_____________________

Image Storage Capacity:_____________

Last Image Hold

Application Platform:_____________________

Tube Model:	_____________________	DOM:	_____________	MHU:	_____________
Image Intensifier Model:	_____________________	Size of II:	_____________	DOM:	_____________

Number of Monitors:

_____________

Type:

_____________________

Line Rate:

_____________

Permanatly Installed Software Options:

Surgical	Option:_____________________FPS:_____________
Angiography	Option:_____________________FPS:_____________
Neurology	Option:_____________________FPS:_____________
Cardiac	Option:_____________________FPS:_____________

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:	_______________________________