Genesis Medical Imaging, Inc. - CT and MRI Equipment, Parts, Service and Mobiles

CT Equipment Request Form
This form will be emailed to our Sales Department.
A sales person will contact you shortly reqarding your request. Thank you.
Questions?? Please contact Ron Ragan at (847) 961-6200
or email: RRagan@GenesisMedicalimaging.com

Customer Information
*Buyer’s Name:
Title:
*Phone:
Fax:
*E-Mail:

Facility
*Facility Name:
*Address:
*City:
*State:

How did you hear of Genesis:
Equip. Need Date:
Special Needs:
Budgeted Dollars:

Single Slice Systems:
HiSpeed Advantage
ProSpeed System
HiSpeed Xi System
CTi (Non-Performix)
CTi ( Performix )

Dual Slice Systems:
HiSpeed CT/e Twin
HiSpeed NXi System

Non-Helical CT Systems:
HiLight Advantage
Sytec Series Systems

4 Slice Systems:
LightSpeed QXi
LightSpeed Plus

8 / 16 Slice Systems:
LightSpeed Ultra (8)
LightSpeed 16 Slice

Stand Alone WorkStation:
Advantage Windows
Rapidia (Lower Cost)

Software Selection:
SmartPrep
SmartBeam
3D Analysis
ConnectPRO
Perfusion
SmartScore
CT Colonography
Adv. Vessel
Adv. Lung
Digital Laser Interface
Analog Laser Interface

Additional Options:
Lease: Term (Yrs):
% Buy Based on Price:
% Buy Based on Feature:
% Buy Based on Service:
Room Drawing: Planning:
Fixed Config. Mobile
As Is, Where Is Condition:
90 Day Warranty:
1 Year Warranty:
Service Contract:
New Tube Installed:

* Required Fields

Genesis Medical Imaging, Inc. 12031 Smith Drive Huntley, IL 60142
Tel: 847-961-6200 Fax: 847-961-6030 Service: 888-891-6990 sales@genesismedicalimaging.com