Radiology OneSource

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

CT 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

Slice	1	2	4	6-8	16	32	64	128
Slice Time:	____________

Generator Model:

_____________________

kW:_____________

mA:_____________

kV:_____________

Computer Model:

_____________________

DOM: _____________

SW Rev: _____________

Archiving

MOD

DAT

PACS

Other:_____________________

Application Platform:_____________________

WorkStation1:	_____________________	Rev:	_____________
WorkStation2:	_____________________	Rev:	_____________
Satellite Console:	_____________________

Gantry Model:

_____________________

Detector Type

_____________________

Slice Count:

_____________

Scan Seconds

_____________

as of

_____________

Tube Model:

_____________________

DOM:

_____________

MHU:

_____________

Air

Oil

Water

Slice Count

_____________

Scan Seconds

_____________

as of

_____________

Tube Install Date

_____________

Housing Type:

_____________________

Permanatly Installed Software Options:

3D	Option:_________________________	Angiography	Option:_________________________
Bolus	Option:_________________________	Bone Mineral	Option:_________________________
Calcium Score	Option:_________________________	Cardiac	Option:_________________________
CT Flouoro	Option:_________________________	Dental	Option:_________________________
DICOM	Option:_________________________	Dose Modulation	Option:_________________________
ECG	Option:_________________________	Fusion	Option:_________________________
MIP	Option:_________________________	MPR	Option:_________________________
Neurology	Option:_________________________	Pediatric Protocol	Option:_________________________
Perfusion	Option:_________________________	Pulmonary	Option:_________________________
Virtual 4D	Option:_________________________	Virtual Colonoscopy	Option:_________________________
VRT	Option:_________________________

Radiation Protection Type:	_______________________________________	Included
Chiller System:	_______________________________________	Included
UPS:	_______________________________________	Included
Power Regulation Device:	_______________________________________	Included

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:	_______________________________