DR Parts Order Worksheet & Call Registration Form

Dealer Information

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Customer Name

Dealer Name*

Reporting Technician*

Reporting Technician Phone*

Reporting Technician Email*

End User Information

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Country/City

Hospital Name*

System Type*

System Serial No.*

S/W Version

Installed Date

Patient Impact*

Impacted
None

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Issued Date

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Issuer Name

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RMS Registration

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GSPN Service Order

Detector Information

Receptor 1*

Type 1*

Serial No. 1

Receptor 2

Type 2

Serial No. 2

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Receptor 3

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Type 3

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Serial No. 3

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Receptor 4

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Type 4

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Serial No. 4

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Receptor 5

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Type 5

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Serial No. 5

System Information

* You must enter detailed information in the required fields.

Problem Type*

H/W Problem
S/W Problem
Image Problem
Exposure/Dose Issue

Occurence Frequency*

Every Time
Daily
Weekly
Monthly
One Time

Problem Description*

System Status*

Neurologica Reviewed/Confirmed By:*

Please type in the name of NeuroLogica Engineer’s name who reviewed this order.

Performed Actions

Please list performed actions and the date they were performed:

Date 1*

Action 1*

Date 2

Action 2

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Date 3

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Action 3

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Date 4

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Action 4

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Date 5

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Action 5

Replaced/Tested Parts

Please add all replaced/tested parts for this system here:

Defective Part No. 1*

Description 1*

Serial # Part 1*

Defective Part No. 2

Description 2

Serial # Part 2

Engineer's Opinion on Customer Status*

Parts Requests

Part Number 1*

Quantity 1*

Description 1*

Need Date*

When do you need your part to arrive?

Part Number 2

Quantity 2

Description 2

Need Date

When do you need your part to arrive?

Part Number 3

Quantity 3

Description 3

Need Date

When do you need your part to arrive?

Part Number 4

Quantity 4

Description 4

Need Date

When do you need your part to arrive?

Part Number 5

Quantity 5

Description 5

Need Date

When do you need your part to arrive?

Coverage & Shipping Information

Coverage Type*

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System Serial #

Dealer PO#*

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Model Code

UPS Shipping Method*

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Customer Tracking

Ship-To Name & Address*

City*

State*

Zip Code*

Contact Name*

Contact Phone Number*

Email for tracking information*

Dealer Agent Signature*

Signature Date*

Form Notification

Please send confirmation to [email protected] to submit this form.

Email Confirmation*

Enter Email Confirm Email

Email Confirmation 2

Enter Email Confirm Email

Email Confirmation 3

Enter Email Confirm Email

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Unique ID