Radiology OneSource

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

Urology 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

Generator

Model:_____________________

kW:____________

mA:____________

kV:____________

Single Phase	Three Phase
High Frequency

Table

Model:_____________________

Tilt Capable

Tilt

90/15

90/30

90/45

90/90

Image Intensifier

Model:_____________________

Size of II:____________

DOM:____________

Overhead Tube Crane

Model:_____________________

Tomo	Model:_____________________

Monitor

Cart

Suspended

Accessories:

	Arm Boards	Infusion Bottle Holder
	Leg Supports	Endoscopy Shelf

Camera

Type:_____________________

Table Top Extension

Workstation

Type:_____________________

Accessory Cart

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:	_______________________________