Ultrasound Installation Card Date MM slash DD slash YYYY Installation LocationLocation Name*(where installed) Contact*(full name and title): Owner (if different) Street Address: Hospital Name: Suite: Clinic Name: City, State, ZIP: Department: E-mail Address:* Phone:Fax:Hospital / Clinic InfoHospitalNumber of beds:Number of Physicians:ClinicNumber of Physicians:Physician Specialties: OB/GYN OB GYN Cardiology Perinatology Urology Radiology Family Practice General Practice Internist Breast Surgeon Emergency Infertility Oncology Other Other: System InformationSystem Model* Serial Number* Software Version* Options* Probe Part Numbers/Serial NumbersProbe Part Number 1* Serial number 1* Probe Part Number 2 Serial number 2 Probe Part Number 3 Serial number 3 Probe Part Number 4 Serial number 4 Probe Part Number 5 Serial number 5 Peripheral Part Numbers/Serial NumbersPeripheral Part Number 1 Serial Number 1 Peripheral Part Number 2 Serial Number 2 Peripheral Part Number 3 Serial Number 3 Peripheral Part Number 4 Serial Number 4 Peripheral Part Number 5 Serial Number 5 Seller / Customer InformationSeller and/or Individual Warranty Term Installer's Name Install Date* MM slash DD slash YYYY Customer Name Title Customer Signature* Date MM slash DD slash YYYY Signature Confirmation*By selecting this check box, the customer acknowledges that the Customer Signature field will server as their digital signature. Agree Disagree Comments:* Mandatory Fields to be populated by Sales Representative ** Customer's signature indicates successful installation and that the system(s), probe(s), and any peripherals have been accepted. *** If this is not the customer's mailing address, please list the mailing address in the comments section. Form NotificationEnter 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 CAPTCHA Δ