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									                                                                                  BAYSIDE MEDICAL EQUIPMENT
                                                                                                               2386 Pacifica Court
                                                                                                          San Leandro, CA 94579
                                                                                               (510) 878-7955 FAX (866) 341-9851
                                                                                         JennyChen@baysidemedicalequipment.com

          DOCUMENT MUST BE SAVED ON YOUR COMPUTER AND EMAILED AS AN ATTACHMENT
                                OR PRINT OUT AND FAX BACK


                                                    CT SCANNER
                                           SPECIFICATIONS & INFORMATION

Your Name                                                                                                     Company:

Phone:                                                                     E-Mail:

Manufacturer:                                 Model:                                                              Date Manufactured:

Date Installed:                               Serial Number:

What is System
                          Spiral                   Multi-Slice                               (# slices:       )               Other
Type:
                                                                                                                       Slices per
Tube Age:                        Size (mHu)              Manufacturer:
                                                                                                                       Second

# Slices on Gantry                            Generator Model:                                                    Generator Size:

Independent Workstation?           Yes          No          Type of Computer:                                     Software Level

Consoles:               Single                              Dual         Does it have DICOM?                            Yes               No

Any Upgrades?             Yes        No                  If Yes, please describe:

Is There a Camera?                   Yes        No         If YES, Model #

Is There an Injector?                Yes        No         If YES, Model #

Is the System in Use?                                                                                                               Yes        No

If yes, how long out of use?                             Where is it located?

Mechanical Condition of Equipment: (10 being best)          1      2   3      4      5   6   7     8      9       10

Cosmetic Condition of Equipment: (10 being best)            1      2   3      4      5   6   7     8      9       10

Do you have Photographs of the Equipment? (please email to JennyChen@BaysideMedicalEquipment.com)                                   Yes        No

When is the System Available for Removal?                Who Serviced the Equipment?

Last PM                                                  Contact Person:

Phone Number:                                            What are you Replacing the System with:



     DOCUMENT MUST BE SAVED ON YOUR COMPUTER AND EMAILED AS AN ATTACHMENT TO
                       JENNYCHEN@BAYSIDEMEDICALEQUIPMENT
                     OR PRINT OUT AND FAX BACK TO (866) 341-9851

								
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