New Site Registration Form

New Site Registration Form

To help us provide excellent Customer Service, please be as thorough and accurate as possible.
Your Information
Your Name

Prefix First Name Last Name
Callback Phone

- Area Code Phone Number
Your E-mail
example@example.com
Dealer Company Information
Dealer Company Name *
Dealer Company Phone Number *

- Area Code Phone Number
Dealer Website
ie. dealercompany.com

Dealer Company Address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Practice (End-User) Information
Practice Name *
Practice Phone Number *

- Area Code Phone Number
Practice Website
ie. footandankle.com

Practice Address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Primary Doctor's Name

Prefix First Name Last Name Suffix
Installed Components
Date of Completed Installation *

- Month - Day Year
Date Picker Icon
Installation Type *
Modality Serial # *
(DR/CR/US/etc)
Modality Model Name
ie. iRay Wireless 14x17
Main Computer Serial # *
Computer Model #
ie. Dell Precision Tower 3420
TeamViewer ID
For easier remote support
Generator/X-Ray Serial #
Generator/X-Ray Unit
ie. PXS710D
Other Installed Components
ie. Workstation PCs, Battery Backup, Monitor, etc.
PO/Invoice Number
Copy of Purchase Order (PO)

Browse File

Cancel of
Completed Installation Photo(s)

Browse Files

Cancel of
Should be Empty: