Please complete the form and CT Systems information below:
* = required field
*Center Name:
*Address:
 
*City, State, Postal Code:
Orthopedic Radiologist:
Radiologist Phone:
Chief Technologist:
Phone:
Fax:
*Email:
  Are you able to copy images to CD?
  Are you able to send images via an internet connection?

Please complete the requested information for each scanner.

Scanner Manufacturer Model Software Version # Extremity Coil
Channels
(MR only)		 # of Detectors
(CT only)
Example
1
2
3
4
5