Title:

Phone *:

Fax:

If United States, please list the state:

Company / Facility:

Equipment Model * :

Year * : Manufacturer * : Select Bennett Continental General Electric Hitachi Liebel-Flarsheim Philips Picker/Marconi Shimadzu Siemens Toshiba Other

Type: Select Angio Cath-Angio Portable Rad R-F Other

Hz:   50Hz   60Hz

Generator:
Size: Model:

X-Ray Tube:
Size:

Model: Age:

Image Intensifier:
Size: Age:
Single Dual Tri-Model Other

Table Model:

Tilt/Motion:

Collimator Model:
Automatic?  Yes No

Camera?: Yes No (If yes, model):

Monitors:
Quantity: 
Ceiling Mounted? Yes No

Digital?: Yes No

Software Release:

OEM Service Contract?: Yes No

Upgrades & Year completed:

Remote Room? Yes No

Wally Bucky or Chest Stand?:  Wally Bucky      Chest Stand

Phototimed?: Yes No

Patients per day:

Deinstalled? : Installed Deinstalled

Availability Date:

System location: Hospital Clinic Warehouse Other

Quote for : Market Valuation Sale