Fax: +1 615-577-1122
Email: Info@radiologyonesource.com
|
Phone: +1 615-577-1RAD(1723) Fax: +1 615-577-1122 Email: Info@radiologyonesource.com |
| Portable Form |
| Manufacturer: | _____________________ | Model: | _____________________ | Production Year: | ____________ |
| S/N: | _____________________ | SiteID: | _____________________ | Available Date: | ____________ |
| SW Rev: | _____________________ | Current Settings | |||
| Originally Purchased | by:_____________________ |
| Collimator | Model:_____________________ |
| Tube Type: | _____________________ | Tube install date:____________ |
| Housing: | _____________________ | Focal Spots:______ ______ |
| Digital System: | _____________________ |
| Flat Panel Detector: | _____________________ |
| Type:_____________________ | Last Replaced:____________ |
| Other Equipment: |
| System is: |
| System is in good working condition and not in need of repair?_____________________ |
| 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: | _______________________________ |