MR Coil Repair Request
MR Coil Repair 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
Coil Information
System OEM
*
System Model
*
Coil ID | Part Number
*
Coil Serial Number *if available
Field Tesla Strength
*
Frequency | MHZ
Coil Issues
This is the description of your section break.
Issues Are
*
Intermittent
Always Present
Happened Once
Will Not Scan
Noisy | Grainy
Producing Artifacts
Unknown
If coil won't scan
TR Driver Fault
Coil Not Identified
No Signal | Frequency Not Found
Other
If Noisy (Check all that apply)
If Noisy (Check all that apply)
Grainy
Low Signal
Washed Out
Poor Contrast
Other
If Artifacts (Check all that apply)
If Artifacts (Check all that apply)
Localized
Global Bright Area
Dark Hole
Shading
Ripple Patterns
Other
If Homogeneity (Check all that apply)
If Homogeneity (Check all that apply)
Poor Uniformity
Fat Saturation Issues
Other
Which section, modes or channels have these problems?
Please describe any error messages or other symptoms the coil is experiencing.
Please select any additional services you would like added to your quote.
Please select any additional services you would like added to your quote.
Loaner *if available
Repaint
Re-Foam
Expedited Service
Current Service Provider
In house service
Independent | 3rd party service
OEM Service
Other
If you'd like to add any photos of the coil ID Badge, error logs or notes of damage please add them here.
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