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Demo Request
Company
Site Name:
Requesting AE
*
Angie Katz
Allan Lloyd
Barry Clot
Dustin Batty
Ian Atkinson
Jake Kerley
Stacey Mitchell
TEST / Michael
Site Address:
*
City
*
State
*
Equipment Type:
*
Canon Ultrasound
Carestream Retrofit
Carestream Revolution
Orthoscan Mini C-Arm
Ziehm C-Arm
Other
Equipment Demo Details:
Contact Name:
*
Contact Email:
*
Contact Phone:
*
Date Start:
*
Date Finish:
*
Sending to PACS or Pulling Worklist?
Yes
No
TKM Delivery?
Yes
No
Engineer Needed?
Yes
No
Box Truck Needed?
*
Yes
No
Vendor Credentialing Required?
Yes
No
Delivery Details:
