Your Name
Your Email Address
Facility Or Company Name
Phone Number
Fax Number
Manufacturer
Date Of Manufacture
Model
What Is Film Size
Number Of Inputs
How Many Keypads Do You Have
Is the System DICOM
Does The System Have A MMU (Multi Modality Image Manager) No Yes
Does The System Have A PACS Link Computer System, If So What Is The Make And Model
Please List The Imaging Systems Interfaced To This Camera, Include Make And Model
When Is The System Available For Removal
When Do You Need An Offer By
Who Is Servicing The System
On A Scale Of 1 To 10, Please Rate The Cosmetic Condition 1 2 3 4 5 6 7 8 9 10
Do Any Walls Have To be Removed To Get The System De-installed No Yes
Is There A Loading Dock At Your Facility Yes No
Asking Price
Any Additional Comments Or Accessories