Customer Info

Customer name

Company or hospital?
CompanyHospital

Phone

E-mail

System Info

Manufacturer

System Name

Date of Manufacture (MMDDYY)

Serial Number

System Fully Functional?
YesNo

Condition
1 (worst)2345678910 (best)

Current Service Contract

Software Version

Available When (MMDDYY)

Inspection Possible
YesNo

Removal Requirements

Other Info

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