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Name
*
First
Last
Email Address
*
Phone Number
Company
Description you?
Which best describes you?
*
--
VP/Dir of Radiology/Imaging Services
VP/Dir of Clinical/Biomedical Engineering
VP/Dir of Supply Chain/Purchasing
Imaging Services Engineer
Owner
Consultant
Other
Equipment Type
*
--
MRI
CT-PET/CT
Ultrasound
Mammography
CATH/Angio
X-Ray
Manufacturer
*
--
Philips
GE
Siemens
Hologic
Samsung
Shimadzu
Equipment Model Number
Description of Model
State of Equipment location
State of Equipment location
Current service provider
*
--
Philips
GE
Siemens
Hologic
Samsung
Shimadzu
Other
Type of Service
*
--
Fixed Rate Contract
Time and Material Repair
Training
Back-Up Labor
Preventive Maintenance Inspections
Technical Support
Message
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