Please complete the form and MR/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