Radiology OneSource

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

DR/X-Ray/RF/Remote/Multi-purpose 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

Remote

Generator

Model:_____________________

kW:____________

mA:____________

kV:____________

Single Phase

Three Phase

High Frequency

Anatomical Programming

X-ray Tube Model:

_____________________

DOM:____________

Focal Spots:______ ______

Tube Crane Model:	_____________________	Overhead	Floor mounted	Floor-wall	Floor-ceiling	Table Integrated
Collimator:	_____________________	Manual	Semi-Auto	Automatic

Tomo	Model:_____________________

Wall Unit

Cassette Stand

Bucky

If Bucky, tilt?

Yes

Photo Timed

DR/RF/Remote/Multi-Purp.

Flat Panel Detector

Model:_____________________

Size:____________

X-ray Tube

Model:_____________________

DOM:____________

Focal Spots:______ ______

Image Intensifier

Model:_____________________

Size of II:____________

DOM:____________

Spot Film Device

Model:_____________________

Size:____________

Digital

Monitor

Cart

Suspended

Cut Film Camera

Model:_____________________

Table

Model:_____________________

Fixed Height

Elevations

Float	None	2-Way	4-Way
Tilt	90/15	90/30	90/45	90/90

Digital System:

Model:	_____________________
SW Rev Level:	_____________________

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:	_______________________________