Register Fill Out The Registration form PI Rep: Customer Bill To: Date: Customer Ship To: Customer: Est Close Date: GPO: Current OEM Vendor Relationships: How did lead come about? What is the need/product/clinical Problem being solved Replace existing or net new purchase? MRI Current MRI IB: Budget: working, early, finalized? Desired MRI: M Decision Makers: Clinical Specialty: P Purchase Process: Channel: C Criteria: Software/OS: C Competitors: Clinical scans desired: Desired Coils: Other Notes: Trade-in? Make/Model/Coils/Pics Software level/OS/Date of Removal CT Current CT IB: B Budget: working, early, finalized? Desired CT: M Decision Makers: Clinical Speciality: P Purchase Process: Slice # array desired: C Criteria: Software/OS/Clinical C Competitors: Trade-in? Make/Model/OS/ SW level/Pics / Date of Removal Other Notes: Cath / IR Lab Current Lab IB: B Budget: working, early, finalized? Desired Lab Make/Model: M Decision Makers: Clinical Speciality: P Purchase Process: Specific procedures: C Criteria: Software/OS/Clinical C Competitors: Trade-in? Make/Model/OS/ SW level/Pics / Date or Removal Other Notes: PETCT Current PETCT IB: B Budget: working, early, finalized? Desired PETCT Make /Model: M Decision Makers: Clinical Specialty: P Purchase Process: Slice # array desired: C Criteria: Software/OS/Clinical C Competitors: Trade-in? Make/Model/OS/ SW level/Pics / Date of Removal Other Notes: RF Current RF IB: B Budget: working, early, finalized? Desired RF Make /Model: M Decision Makers: Table type: Conventional / Remote P Purchase Process: New or Refurb? C Criteria: Detector or II size? C Competitors: Overhead xray needed? Automated system needed? Trade-in? Make/Model/OS/ SW level/Pics / Date of Removal Procedures performed: Submit
