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MRI Fair Market Evaluation Form

 

 

Please Complete Form and Hit "Submit"


MRI 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:
Manufacturer:
 Model Name:
Year Originally Installed: Software Level :
OEM System ID #:  
MRI Field Strength:
MRI Type ?
Fixed Site Mobile
Modular Transportable		 Magnet Shielding:
Unshielded Passively Shielded
Actively Shielded
Approximately When Will System Be Available?:
Date System Will be Available?:
Magnet Type:
Permanent
Resistive
Superconductive		 Cryogens:
Single Cryogen System
Dual (Nitrogen & Helium)
None
Gradient Strength M/T:
Coils:
Head
C-Spine
Quad-Knee
Quad T/L-Spine
Shoulder
Extremity
CTL
Torso Array
TMJ
Neurovascular
GP Flex
Others
Host Computer :
Genesis
Indigo
Octane
Sun Sparc 1
Sun Sparc 2
Sun Sparc 10
Other:
Special Features :
FSE MRA Cardiac EPI Phased Array
Profusion/Diff Smart Prep
Additional Features or Comments:
Physical Condition: (1-10, 10=Excellent):
Second Console : Yes No If Yes, Is it a Workstation? Yes No
Is the System Under a Service Contract? Yes No
Company Handling Service to Date?
DICOM Ready?:
Yes No		 Laser Camera Included:
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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