Your Name

Your Email Address

Facility Or Company Name

Phone Number

Fax Number

Manufacturer

Date Of Manufacture

Generator Model  

Is it Single Or Three Phase Three Phase Single Phase

Is It High Frequency No Yes  

Maximum MAs

Table Model

Does It Tilt 90/15 90/30 90/45 90/90

Is It 2 Way Or 4 Way 2 Way 4 Way

Type Of Overhead

Age and Size Of The Image Intensifier

Model Of The Digital System With Revision

Model and Age Of The X Ray Tube  

Model Of The Spot Film Device

Is There A Wall Bucky Yes No

Number Of TV Monitors

Does The System Have A Tomo Attachment

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

When Is The System Available For Removal

When do You Need An Offer By

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