Service Request Form
Hospital/Institution* :
Address* :
Contact Details
Name* :
Telephone / Mobile No.* :
Fax No. :
Email* :
Please Select the Equipment you want Quality Assurance for :
Equipment #1:
X Ray - Radiography
X Ray - Fluoroscopy
Portable X-Ray
X Ray - Fluoroscopy and Radiography
C-Arm
Digital Radiography System
Intra-Oral Dental X-Ray
Dental OPG
Mammography
CT Scan - Single X-Ray Tube
CT Scan - Dual X-Ray Tube
Cathlab
Bone Mineral Densitometry
Quantity :
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Radiation Protection Accessories :
Accessory #1:
Lead Apron
Thyroid Apron
Gonad Apron
Lead Goggles
Quantity :
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Other Equipment or Accessories :
(* Fields are Required Fields)
