Service Execution Request Form

Training Request Form

Thanks for choosing the Imaging Diversified team for your training needs. Whether you are a vendor or imaging provider we will be sure to provide the best quality training we can to make sure technologist are equipped with the knowledge to operate their equipment effectively. We provide training for all equipment manufacturers for both MRI and CT. We also provide training for US, Pet/CT, Xray and more depending on availability. Enter your request and we will have a confirmation of availability within 48hrs. Preferred Vendors follow Cost sheet on agreement.
Training Day Cost Estimate

1 day = $2250, 2 day = $3500, 3 day = $5000, 4 day = $6500, 5 day = $7750 (Pet/CT training is additional cost based on days and training needs)
Name*

First NameLast Name
Email*
example@example.com
Company/Vendor*
Requester
Modality*
System Manufacturer*
System type. List full description in next section if not listed.
System name and software (if available)
List software level. Full system name and software if not available in dropdown manufacturer list.
Expected Start Date*

MonthDayYear
Date
Expected End Date*

MonthDayYear
Date
Training Cost

*Without monthly support* 1 day = $2250, 2 days = $3500, 3 days = $5000, 4 days = $6500, 5 days = $7750. *With monthly support* 1 day = $1500, 2 day = $3000, 3 day = $4000, 4 day = $5500, 5 day = $6750. ($500 surcharge added to STAT request within 7 days) (Pet/CT surcharge amount notified at confirmation).
Facility Name and/or Location (Address) receiving the training *
Please list full address
Facility Contact name, email and number receiving the training
Please list if available
Any Additional Notes for this request.
Put notes here or specific details for training. Cardiac need? Lockbox/door code? New Tech? Workstation/Injector training?
File Upload

Upload any files here
Cancelof
Brand Ambassador/Partner Affiliate
List full name if in our Affiliate program or a Brand Ambassador for Imaging Diversified and have completed orientation. Leave blank if you have not completed signed agreement and orientation.
Type of Service Request (Training/Apps, Staffing, Accreditation help)
Select an option
Request Status
Select an option
Trainer Name

First NameLast Name
Trainer Name 2

First NameLast Name
Invoice Number
Invoice Amount
Trainer Cost/Payment
Including expenses
$1000 is due within 48hrs of confirmation of trainer. Remainder Due in full 2 business days before training start date. If PO is needed please supply at time of request in Notes section.

Ask about our monthly support packages. All monthly support customers receive training discounts.
Should be Empty:

Training Request Form

Training Day Cost Estimate

Training Cost

$1000 is due within 48hrs of confirmation of trainer. Remainder Due in full 2 business days before training start date. If PO is needed please supply at time of request in Notes section.