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MRI Coil Repair Form
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Coil Information
Model Number:
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Serial Number:
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Coil Description:
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MRI Frequency:
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Field Strength:
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Problem Description
Brief description of problem:
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Is the problem:
Intermittent
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Happened once or Don't know
Additional information
Will not scan
High Noise or Grainy Images
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Mechanical Problem(Please specify below)
For Artifacts:
Localized
Global Bright Area
Dark Hole
Shading
Ripple Patterns
If Homogeneity:
Poor uniformity
Fat Saturation problem
If Coil Won't Scan
TR Driver Fault
Coil not identified
No Signal or Frequency not found
Are any system error messages shown?
Other symptoms or problems:
Which section, modes, or channels?
Please specify which sections, channels, modes have the problem? (i.e., C-section on CTL coil)
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Sell Your Used Scanner
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Date of Manufacture*
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Describe Your Imaging Project and Reason for Sale
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Functional?
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Site ID
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System Serial Number and Magnet Serial Number
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Software Revision Level(Options enabled on system, rev level, other features, and hardware)
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Current Service Provider
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Clinic
Loading Dock at Facility
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Diagnostic Imaging Equipment Quote Request
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