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Request For Information: Interim MRI Solutions

So we can respond in a thorough and timely manner, please complete the following questions. Fields marked by * are required.

First Name *:
Last Name *:
Title :
Facility Name *:
Address:
City:
State *:
Zip:
Phone *:
Fax:
Email:
Manufacturer of Equipment Requested:
Magnetic Field Strength Requested:
Date System is Requested (mm/dd/yyyy):
Termination Date (mm/dd/yyyy):
Transportable or Modular Building Required:Yes No Unknown
This System is Requested Due to:

Special Requests: Special Delivery Requests (i.e. Surface Coils, Phased Array, Technologists, Applications, Siting Issues, etc...)


The following information will assist us in configuring an interim solution to meet or exceed your current system performance measures.

Manufacturer of Current MRI System:
Model of Current System:
Magnetic Field Strength of Current MRI System:
Age of Your Current System:
Is This System Being Replaced:Yes No



 
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