TraveLab Request Form
This form is a request for our single station mobile lab. See more info at kraftmed.com/travelab
REQUESTOR INFORMATION
Company Name
Requestor
Phone
E-mail Address
example@example.com
Start Date of Event
/
Month
/
Day
Year
Date
End Date of Event
-
Month
-
Day
Year
Date
Start Time of Lab:
Hour Minutes
AM
PM
AM/PM Option
End Time of Lab:
Hour Minutes
AM
PM
AM/PM Option
FACILITY INFORMATION
Facility Name
Type of Lab (Anatomy)
On Site Contact Name
On Site Contact Phone
Address
Lab Address
Street Address Line 2
City/State/Zip
State / Province
Postal / Zip Code
DELIVERY INFORMATION
Date of Delivery
/
Month
/
Day
Year
Date
Time of Delivery
Hour Minutes
AM
PM
AM/PM Option
Date of Pickup
/
Month
/
Day
Year
Date
Time of Pickup
Hour Minutes
AM
PM
AM/PM Option
Delivery/Set up Instructions
Type of C-arm
Full-Size
Mini
None
EQUIPMENT INFORMATION
Number of Lead Aprons
(10 included with each full-size C-arm, 5 included with mini c-arm)
Additional C-Arm needs?
OTHER OFFERINGS
Red Bags
Please Select
No
Yes
Sharps Container
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
1 RT included per full size C-arm (up to 6 hours), NO RT included with Mini C-arm
Start Time for Tech(s)
Hour Minutes
AM
PM
AM/PM Option
End Time for Tech(s)
Hour Minutes
AM
PM
AM/PM Option
BILLING INFORMATION
Name
Address
E-mail Address
example@example.com
E-mail Address
Please Select
Yes
No
Job Reference/Purchase Order Number
Submit
Should be Empty: