Special Procedure Room Data Sheet
Your Name
Your Email Address
Facility Or Company Name
Phone Number
Fax Number
Manufacturer
Date Of Manufacture
Single Or Biplane Single Bi Plane
Type Of Studies Performed
Generator Model
Table Model
Does The Table Have a Stepping Top Yes No
Type Of C Arm
Age and Size Of The Image Intensifier
Model Of The Digital System With Revision
Model and Age Of The X Ray Tube
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