Radiology OneSource

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

MRI 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:	____________
VIN:	_____________________	SiteID:	_____________________	Available Date:	____________
SW Rev:	_____________________	Current Settings 50Hz 60Hz

Magnet Name

_____________________

Type

Permanent

Resistive

Super-conductive

Single Cryo

Dual Cryo

Magnet Design

Short Bore

Medium Bore

Long Bore

Open

Config/if upgrade

Originial

Upgrade

Install Date:____________

Shielding

Active

Passive

External Magnetic

Mini

Full

Field Strength

0.2T-0.7T

0.5T

1.0T

1.5T

3.0T

Other:____________

Helium Level:

____________

Last Fill:____________

Last Cold Head Replacement:____________

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

Permanatly Installed Software Options:

3D	Option:_____________________	Angio	Option:_____________________
Bolus	Option:_____________________	Breast	Option:_____________________
Cardiac	Option:_____________________	Core	Option:_____________________
EPI	Option:_____________________	FSE	Option:_____________________
MRA	Option:_____________________	Neuro	Option:_____________________
Perfusion	Option:_____________________	Phased Array	Option:_____________________
Spectroscopy	Option:_____________________	Turbo	Option:_____________________
Other	Option:_____________________

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.

Coil 1	_____________________	Linear	Phased Array	Quadretuee	Needs Repair
Coil 2	_____________________	Linear	Phased Array	Quadretuee	Needs Repair
Coil 3	_____________________	Linear	Phased Array	Quadretuee	Needs Repair
Coil 4	_____________________	Linear	Phased Array	Quadretuee	Needs Repair
Coil 5	_____________________	Linear	Phased Array	Quadretuee	Needs Repair
Coil 6	_____________________	Linear	Phased Array	Quadretuee	Needs Repair
Coil 7	_____________________	Linear	Phased Array	Quadretuee	Needs Repair
Coil 8	_____________________	Linear	Phased Array	Quadretuee	Needs Repair
Coil 9	_____________________	Linear	Phased Array	Quadretuee	Needs Repair
Coil 10	_____________________	Linear	Phased Array	Quadretuee	Needs Repair

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

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:	_______________________________