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RISMED Services - Simulator Evaluation Form
Please complete this evaluation form on the Simulator becoming available at your facility. We will respond to your inquiry as quickly as possible.

Contact Information
Name:
 Company:
Title:
 Address:
Address 2:
 City:
State/Province:
 Zip/Postal:
Country:
 Telephone:
Fax:
 Email:


Simulator Information
Brand
 Model
Year
 Serial #


Image Intensifier
Brand
 Model
Field Size(s)
 Age


X-Ray Tube
Brand
 Catalog/Model
 Age


Generator
Manufacturer
 Model
Select Type:
1-Phase   3-Phase   High Frequency (HF)


General Information
How many monitors included?
 Screen Size(s)


Does the system include:
Yes No     Lasers
Yes No Manuals
Yes No Spare Parts Kit


Unit Availability
Is unit still in service: Yes No
If yes, date unit be available for deinstallation? / /
If no, how long has unit been out of service:
Last date serviced: / /


Condition of Unit
Would you rate this unit as:
Reliable     Good w/minor problems     Unreliable
Unit uptime%


Terms of Sale
Accepting offers until / /
Asking price $
Dept. & Contact Person
Comments:

Note: Sub-base frame/rails are part of the installation of this unit. RISMED reserves the right to remove the sub-base frame and/or rails at its own expense.

 
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