DR Parts Order Worksheet & Call Registration Form

Dealer Information

Hidden

Customer Name

Dealer Name*

Reporting Technician*

Reporting Technician Phone*

Reporting Technician Email*

End User Information

Hidden

Country/City

Hospital Name*

System Type*

System Serial No.*

S/W Version

Installed Date

Patient Impact*

Impacted
None

Hidden

Issued Date

Hidden

Issuer Name

Hidden

RMS Registration

Hidden

GSPN Service Order

Detector Information

Receptor 1*

Type 1*

Serial No. 1

Receptor 2

Type 2

Serial No. 2

Hidden

Receptor 3

Hidden

Type 3

Hidden

Serial No. 3

Hidden

Receptor 4

Hidden

Type 4

Hidden

Serial No. 4

Hidden

Receptor 5

Hidden

Type 5

Hidden

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

Hidden

Date 3

Hidden

Action 3

Hidden

Date 4

Hidden

Action 4

Hidden

Date 5

Hidden

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*