System Request
System Request
Company Name
*
Requester Name
Requester Name
*
First
Last
Email
*
Phone
Phone
*
-
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-
###
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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
System 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
*
Is this system needed for a mobile or fixed location?
Mobile
Fixed Site
Need by Date
Need by Date
/
MM
/
DD
YYYY
Are any Logistics going to be needed for this project? Please select all that may apply.
Are any Logistics going to be needed for this project? Please select all that may apply.
Shipping
Installation
Removal of current system
Build out
Other
Additional project details