Radiology OneSource

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

Gamma Camera 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		110-130 Vac 220-240 Vac

Head Count

Single, Dual, Triple?_____________________

Orbiter

Extended Reach

Digitrac

List Collimators Included:	__________________________________________
Collimators Carts	_____

Exchanger:

Automatic

Semi-Automatic

Manual

System

Spect

Planar

Cardiac

Whole Body

General Purpose

Vascular

Thickness of Crystals:_____________

Detector

Square

Round

Size: ________ x ________

Original Crystal Replaced

Last replacement date:_____________

Controls Integrated

Analog

Digital

Computer Information:

Computer Included

Comp Platform Type:_____________________

Integrated

DOM	_____________
SW Type	_____________________
SW Level	_____________________

Monitor	type:_____________________	Color B/W	Quantity:_____________
Printer	type:_____________________
Imager/Multiformatter	type:_____________________
R Wave Trigger	type:_____________________
Second Workstation	type:_____________________

Other Equipment:

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:	_______________________________