Ultrasound CAS Install and Follow Up Report Clinical Applications Specialists (CAS) Contact InformationCAS Name* First Last CAS Email Address* Supporting CAS Name Facility Name* Facility Address, City and State* Street Address City State / Province / Region ZIP / Postal Code Facility Administrator Contact* Facility Administrator Contact Email Address Lead Technologist Name* Lead Technologist Email Address* Install or Follow Up*Select OneInstallFollow UpSystem Installation Date by Service* MM slash DD slash YYYY Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Sales Representative* Sales Representative Email Ultrasound Segment*Select OneRadiologyPOCWomen's HealthVetWH Dealer or Direct*Select OneDirectExcelMCSMMICPMIPremier Medical SystemsWH Segment*Select OneMFMOB/GYNREIL&DPregnancy ResourceUrologyPediatric CardiologyFetal SurgeryWH -Ultrasound System*Select OneHera i10Hera W10Hera W9V8V7HS60HS50HS40HM70 EVORS85RS80WS80HS70Radiology Direct or Dealer Partner, POC or Vet*Select OneDirect-AmyDirect-RobRad DealerPOC DealerVet DealerRadiology Dealer*Select OneCommonwealth X-RayExcelMid-South Medical ImagingMidwest Medical Imaging CorpRadSource ImagingRPSPOC/Vet Dealer*Select OneAvanteChoiceMMICRad-Ultrasound System*Select OneRS85 PrestigeRS85V8V7HS60HS50HS40HM70 EVORS80HS70POC Ultrasound Systems*Select OneRS85 PrestigeRS85V8V7HS60HS40HM70 EVOVet Ultrasound System*Select OneRS85 PrestigeRS85V8V7RS80HS30HS40HS50HS60HS70HM70 EVOAdvanced Features Radiology/POC/VET* Biometry Assist 3D/4D EzHRI S-Shearwave S-Shearwave Imaging Liver Analysis Pkg TAI TSI LumiFlow MV-Flow MV-Flow + LumiFlow Pkg E-Breast E-Thyroid ADVR 2.0 S-Detect Breast S-Detect Thyroid CEUS+ 3.0 ECG Strain+ Stress Echo Arterial Analysis 2D NT Fusion & Track HW Pkg No Advanced Features Purchased Other OtherAdvanced Features Women's Health* 3D/4D HeartAssist ViewAssist 5D Technologies MV-Flow Elastoscan + E-Cervix Smart 4D Lite Uterine Contour Slice A 2D NT Needle Mate+ Crystal Vue/Cystal Vue Flow EzExam+ 2D Follicle UterineAssist ShadowHDR LaborAssist Other OtherWS80 Transducers* CA1-7A CA2-9A CA3-10A CV1-8A EV3-10B EV2-10A EA2-11B EA2-11AR EA2-11AV LA2-9A LA4-18B Other OtherRS85 Prestige and v1 Transducers* CA1-7A CA1-7S CA3-10A CA2-8A CA4-10M CF4-9 CV1-8A EV3-10B EV2-10A EA2-10B E3-12A LA2-14A LA2-9A LA2-9S L3-12A LA4-18A LA4-18B LM4-15B LA3-22AI LV3-14A EV3-10B PA1-5A PA3-8B PA4-12B EA2-11AR EA2-11AV CW6.0 DP8B MMPT3-7 Other V8 Transducers* CA1-7S CA3-10A CA4-10M CV1-8A EV2-10A LA2-14A LA2-9S LA2-9A LA3-22AI LA4-18A PA1-5A PA3-8B EA2-11AR/AV CW6.0 DP8B MMPT3-7 Other OtherHera I10, W10 or W9 Transducers* CA1-7A CA3-10A CA2-9A CF4-9 CV1-8A EV2-10A EA2-11AR EA2-11B Other OtherHS60 Transducers* CA1-7AD CA2-9AD CV1-8AD CA3-10A EA2-11AR EV2-10A LA3-14AD Other OtherHS50 Transducers* CA2-9AD CV1-8AD LA3-14AD EVN-4-9 EA2-11AR EV2-10A Other OtherHS40 Transducers* CA2-8AD EVN4-9 VN4-8 EV2-10A LA3-16AD Other OtherHM70 EVO Transducers* CA1-7AD CA2-8AD CA4-10M VN4-8 EVN4-9 LA3-16AD PE2-4 P3-8 VN4-8 Other OtherPlease list Serial Number for Transducers*System DetailsSystem Serial Number*System SW Level* Technologists and Physicians Trained*Was a "Back Up" Done? Where Was it Left?*Is this customer using Trophon for HLD?*YesNoWhich Trophon Model?*EPRTrophon 2Is Customer using wipes to clean Console and/or Transducers? If so, which wipes?*Customer PAC's System* Training Summary*Current Customer Equipment*Any Concerns for a Successful Adoption of New Samsung System?*Concerns/IssuesImmediate CAS Concerns for Follow Up*Customer Concerns Separate from VoC (VoC Link at End of Form)*Do the Systems Being Installed Need Service Attention?*Select OneYesNoService ConcernsService Representative Service Email **for Dealer Install only** Auto Generated for BI Direct Sales Perceived Customer Satisfaction*Select OneExtremely DissatisfiedDissatisfiedNeutralSatisfiedExtremely SatisfiedInstall ChecklistMax. file size: 50 MB.If the option box does not appear, please ensure your web browser allows pop-ups.CAPTCHA Δ