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CT Fair Market Evaluation Form

 

  

 

Please Complete Form and Hit "Submit"

CT Fair Market Evaluation Form
Please Fill Out This Form, Answering ALL Questions
and Hit the SUBMIT Button at the Bottom of the Form
Name:
 Phone:
Facility Name: Address Where Equipment is Installed:
E-mail Address:
Fax Number:
OEM Make:

Model Name:
Date of Manufacture:
System ID Number:

Under Service Contract?
Yes No

If Under Service Contract, Name of Company Servicing System:
Condition: 1-10, (10 = Excellent:)
Cosmetic Condition: Mechanical Condition:
Type: Spiral Non-Spiral
Spiral Length in cm: 		Independant Workstation?
Yes No
Console: Single Dual Software Revision Level:
Software Options:
3D
Angio
MPR
Dental
Bone Density
CT Fluoro
Cardiac
Other
Tube Manufacturer Name:
OEM Tube Replacement
Tube Size (MHU): 1.5 2.0 3.5 5.0 Other:
# Slices on X-Ray Tube?: No. of Slices on Gantry?:
Computer Model: Optical Disk Mag Tape
Floppy
Generator Model/(kW): Does it have DICOM? Yes No
Laser Camera Included:
Yes No		 Injector with System:
Yes No

Please SUBMIT the completed form to MagnaServ for a Free Fair Market Evaluation. You may print the form and and fax to (772) 283-2450 or hit the Submit button to automatically e-mail this form.

 

MagnaServ, Inc. • 2862 SE Monroe St. • Stuart, FL 34997
Phone Toll-Free: 1-866-283-4288 • Parts Sales (772) 219-2229 • Fax (772) 283-2450






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