Radiology OneSource

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

Mammography 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

Tube Type

_____________________

Exposure Count

____________

Housing

_____________________

Focal Spots

______

Compression

Manual

Automatic

Magnification

SID

Fixed

Variable

Range:_____________________

Phototiming

____________

Number of Paddles

Compression:

____________

Spot:

____________

Magnification:

____________

Biopsy:

_____________________

Other:

_____________________

Number of Apertures:

____________

Accessory Cart Included

Bucky

18x24

24x30

Auto ID

Label Printer

Glass Shield

Cracks

Stereotactic upright device model:

_____________________

Prone table model:

_____________________

Tube Type

_____________________

Exposure Count

_______

Housing

_____________________

Focal Spots

_______

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:	_______________________________