Your Name

Your E mail Address

Facility Or Company Name

Phone Number

Fax Number

Manufacturer

Date Of Manufacture

Model

Is the system single or multi-slice Single Slice 2 Slice 4 Slice 6 Slice 8 Slice 10 Slice 12 Slice 16 Slice 32 Slice 64 Slice 128 Slice

If The System Is Helical, How Fast Can is do a Full Rotation 0.5 Second 1.0 Second 1.5 Second   

Number Of Slices or Scan Seconds On Gantry Slices Scan Seconds

Number Of Slices Or Scan Seconds On Tube Slices Scan Seconds

Model and Heat Unit Rating Of The Tube

What is the Size Of The Generator

Number Of Consoles 1 2 3

Is There a 3D Workstation Yes No What Model

Type Of Computer

Software Level

Diagnostic Packages i.e.  Angio, Dental

Type Of Storage Device

Is There An Imager Included Yes No Model

Who Is Servicing The System

When Is The System Available For Removal

When do You Need An Offer By

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

 

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