Your Name

Your Email Address

Facility Or Company Name

Phone Number

Fax Number

Manufacturer

Date Of Manufacture

Model  

Is it Single Or Three Phase Three Phase Single Phase

Is It High Frequency No Yes  

Does It Have Phototiming Yes No  

What Is The Age Of The X Ray tube

Does It Have a 18 x 24 Bucky Yes No

Does It Have A 24 x 30 Bucky Yes No  

Does It Have Small And Large Cassette holders

Number Of Compression Paddles

Does It Have A Magnification Stand

Does It Have A Needle Biopsy Guide Yes No

Does It Have A Patient ID Printer Yes No  

Does It Have A Patient ID Flasher Yes No

Does It have a Glass Shield Yes No Any Cracks No Yes

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