Samsung GM85 Installation Checklist

Dealer Information
* or required Indicate Required Fields
Dealership Name*
Submitter's Name*
Submitter's Phone*
Submitter's Email
Site Information
Site Name*
Address*
Address 2
City*
State / Province / Region*
ZIP / Postal Code*
Contact Name*
Contact Title*
Contact Phone*
Contact Email
X-Ray Room Information
Equipment Manufacturer
Model
Date of Manufacture
MM slash DD slash YYYY
Samsung GM85 System Information
System Serial No.*
Detector Serial No.*
Detector Serial No.
Software Version*
THU Version
External MAC Address*
Service Tag#
Install Date*
MM slash DD slash YYYY
First Clinical Use*
MM slash DD slash YYYY
DICOM & Network Information
Station Name
AE Title
IP Address
Subnet Mask
Gateway
DNS
Internal WIFI Information
WIFI Name
WIFI Password
Channel
Signal Strength at Wall
Signal Stregnth at Table
Does Channel Have Traffic?
- Yes
- No
List Names of Channel Traffic
Exposure Delay
Exposure Delay
Form Notification
Enter the email address for the person who should receive this form
Email Confirmation*
Enter Email Confirm Email
Email Confirmation 2
Enter Email Confirm Email
Email Confirmation 3
Enter Email Confirm Email

Dealer Information