Name*

Position/Title

Clinic/Facility

Industry: ---VeterinaryOrthopedicChiropracticUrgent / Primary CareRadiology / Imaging Centers

Address

City State Zip

Email*

Phone Fax

Please contact me by: Email Phone

Best time to reach: 123456789101112  AM PM

Which product/s are you requesting a quote for:
 X-ray Digital CR/DR CT/MRI PACS Image Management Other

Any specific model?

Reason:  Upgrade New Facility Replacement Other

What type of exams do you generally perform?

Are there any requirements you want to make sure you meet with this system?
(ie. New capabilities, image quality, ROI, improved reliability, etc.)

Would you like information on financing?  Yes No

What’s your role in the overall decision making process?
---Decision-makerInfluencerJust gathering information

How soon do you need to see a solution in place?
---1 month3 months6 months1 yearbudgeting for future

Any other comments you’d like to add:



How did you hear about us?
 Referral – if so, who? Internet search Flier / ad /email Other