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
Cloud-Backup Service *
*free 1-year Cloud-Backup Service if included at POS, requires end-user agreement
Cloud-Backup Service Point-of-Contact (for Setup/Installation and confirmation):
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email
example@example.com
Installed Components
Date of Completed Installation *

Month Day Year
Has the End-User been provided all documentation for the devices sold, including official user manual, and quality assurance guides for proper device use? (see links below) *

Yes No
Konica Minolta References

PRODUCT MANUALS
KM UNIVERSITY

20/20 Imaging References

FULL DEVICE MANUALS
QUALITY ASSURANCE (see Preventative Maintenance)
TECHNIQUE GUIDE
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:

New Site Registration Form

Your Information

Dealer Company Information

Practice (End-User) Information

Installed Components