Hospital/Clinic/Company:*

First Name:*

Surname:*

Position:*

Address:*

Country:*

Phone:*

Fax:*

E-mail:*

Reason for needing a mobile interim:

Tendering Waiting list/ Temporary demand Replacement System is broken Upgrade Other (please specify)

If 'Other' please specify:

Modality required:

MRI CT CC PET

System/Model required:

GE 1.5T Signa MR/i TwinSpeed GE 1.5T Signa MR/i EchoSpeed Plus GE 1.5T Signa MR/i HighSpeed GE 1.0T MRI Signa Horizon 5X Philips 1.5T MRI Intera Master Siemens 1.5T MRI MAGNETOM Symphony Maestro Class Siemens 1.0T MRI MAGNETOM Impact Expert GE CT LightSpeed Plus Multi Slice GE CT HiSpeed FX/i Plus GE CT Prospeed SX Advantage GE CT Prospeed SX Power Philips CT Tomoscan AV GE Cath Lab Advantx DX-C HiLine System GE PET Advance NX/i

I require a mobile interim:

From:

To:

Or specific month:

Length of rental:

Please tell us if you have any specific requirements i.e. a site survey: