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