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Request For Information: Interim PET/CT 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:

Do you have a current Radioactive Materials License (RAM)?
Yes No

Manufacturer of Equipment 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. Billing Support, NRC Licensing, Technologists, Applications, etc...)


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

Manufacturer of Current PET System:
Model of Current System:
Age of Your Current System:
Is This System Being Replaced:Yes No



 
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