Part Request
Part Request
Company Name
*
Requester Name
Requester Name
*
First
Last
Email
*
Phone
Phone
*
-
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Best Form of Contact
*
Email
Phone
What is your specialty
*
Ambulatory
Equipment | Parts Dealer
Hospital
Imaging Center
Independent Service Provider
Oncology
Orthopedics
Pain Management
Physician Practice
University | College Medical Program
Other
Part Information
System Type
*
Bone Dense
C-Arm
Cath | Angio
CR
CT
Dexa
DR Panel
Imager
Lunac
Lithio
Mammo
MR
Nuclear
PACS
PET
PET|CT
SPECT|CT
Portable X-Ray
Rad Room
RF
Ultrasound
Other
System OEM
*
System Model
*
Part Number
*
Short Description of Part
Purchase Option
*
Exchange
Outright
Both
Do you need an installation quote for this part?
Yes
No
Maybe