MRI Coil Repair Form | Loaner Coils Available & Exchange Buying Options

Contact Name:*

Organization:*

Company/Hospital/Imaging Center

Contact Phone*

Contact Email:*

Facility Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Coil Information

Model Number:*

Serial Number:*

Coil Description:*

MRI Frequency:*

MHz

Field Strength:*

T

Brief description of problem:*

Is the problem:

Additional information

For Artifacts:

If Homogeneity:

If Coil Won't Scan

Are any system error messages shown?

Shipping Account Number (Optional)

If left blank, we will use our account.

Please ship via:*

Shipping*

Repair Fees to be paid by:*

Credit Card (Please call with credit card information. Numbers not kept on file)
Net 30 terms (For credit approved customers only)
Wire Transfer
Check To Be Mailed

Shipping Insurance Value $*

PO#*

Name

First Last

Phone

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country