EVENT SUPPORT REQUEST FORM
REQUESTOR INFORMATION
Company Name
*
Division
Requestor
*
Phone
*
Format: (000) 000-0000.
E-mail Address
*
example@example.com
Start Date of Event
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date of Event
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Start Time of Lab:
Hour Minutes
AM
PM
AM/PM Option
End Time of Lab:
Hour Minutes
AM
PM
AM/PM Option
What type of support are you requesting?
*
Equipment and RTs
Equipment only
RT staffing only
Event coordination
Other
FACILITY INFORMATION
Facility Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What type of lab?
*
Fixed location, i.e. in a building
Mobile lab, i.e. in a truck trailer
Other
If the event is in a room with carpeting, do you have hard surface flooring to position under the C-arm equipment?
No, I need to request hard surface flooring from Kraft Medical
Yes, I am providing hard surface flooring
The event space is all hard surface flooring
Other
Type of Lab (Anatomy)
*
On Site Contact Name
*
On Site Contact Phone
*
Format: (000) 000-0000.
DELIVERY INFORMATION
DELIVERY INFORMATION
Please note that the date and time of delivery will be confirmed closer to the date of the event. We cannot guarantee your exact time requested.
Date of Delivery
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Delivery Requested
*
Hour Minutes
AM
PM
AM/PM Option
Date of Pickup
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Pickup Requested
*
Hour Minutes
AM
PM
AM/PM Option
Please verify that all loading areas, including elevator, are at least 64" x 54"
*
I have verified all loading areas
I am not sure of the loading areas' dimensions at this time
Delivery/Set up Instructions
EQUIPMENT INFORMATION
EQUIPMENT INFORMATION
Type of C-arm
Full-Size Ortho/general
Full-Size 12" Ortho/general (additional cost will apply)
Full-Size Vasc (additional cost will apply)
Full-Size 12" Vasc (additional cost will apply)
Mini
None
Number of C-Arms
Number of Lead Aprons
(10 included with each full-size C-arm, 5 included with mini c-arm)
Number of Tables
Will you need images saved? Any additional C-Arm needs?
OTHER OFFERINGS
OTHER OFFERINGS
Portable Hard Surface?
Please Select
No
Yes
*Required for carpeted floors
Plastic Floor Covering?
Please Select
No
Yes
*Required for carpeted floors
Sharps Container?
Please Select
No
Yes
Red Bags?
Please Select
No
Yes
Light Source?
Please Select
No
Yes
Quantity
Suction
Please Select
No
Yes
Quantity
Smoke Evac?
Please Select
No
Yes
Quantity
Camera Setup?
Please Select
No
Yes
Quantity
PPE?
Please Select
No
Yes
Quantity
On Site Additional Support?
Please Select
No
Yes
Quantity
Other?
RADIOLOGIC TECH (RT) INFORMATION
RADIOLOGIC TECH (RT) INFORMATION
1 RT included per full size C-arm (up to 6 hours), NO RT included with Mini C-arm
Number of Days for RTs
1
2
3
4+
Day 1 - Number of Radiologic Technologists Requested
Day 1 - Start Time for RT(s)
Hour Minutes
AM
PM
AM/PM Option
Day 1 - End Time for RT(s)
Hour Minutes
AM
PM
AM/PM Option
Day 2 - Number of RTs Requested
Day 2 - Start Time for RT(s)
Hour Minutes
AM
PM
AM/PM Option
Day 2 - End Time for RT(s)
Hour Minutes
AM
PM
AM/PM Option
Day 3 - Number of RTs Requested
Day 3 - Start Time for RT(s)
Hour Minutes
AM
PM
AM/PM Option
Day 3 - End Time for RT(s)
Hour Minutes
AM
PM
AM/PM Option
Days 4+ RT Request Details
Other notes about RT request and times
BILLING INFORMATION
BILLING INFORMATION
Name
*
Address
E-mail Address
*
example@example.com
Billing Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Payment Method
*
Please Select
ACH (no fees)
Check (no fees)
Credit Card (3.5% processing fee)
Digital Payment Link (3.5% processing fee)
Job Reference/Purchase Order Number
Promo Code
Submit
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