Radiology Support Request Form
Please fill out this form to report your radiology-related issue. Our team will review and respond promptly.
Full Name
*
First Name
Last Name
Email Address
Helpful to follow-up but not necessary
Phone Number
*
Best direct number to respond to this request. *If sent to a directory or main line number request may not be fulfilled*
Format: (000) 000-0000.
Alternate Number (Office or Cell)
Best direct number to respond to this request. *If sent to a directory or main line number request may not be fulfilled*
Format: (000) 000-0000.
Service Company Name (Who maintains your equipment)
*
Who services your equipment currently? Put N/A if you don't have an active service company. DO NOT LIST YOUR FACILITY UNLESS YOU HAVE AN AGREEMENT DIRECTLY FOR SUPPORT ONLY)
List Modality, Equipment Manufacturer and Software level (if known)
*
Ensure the right person responds!!! This is important
Issue Category
*
Please Select
Image Quality
Equipment Malfunction
Protocol addition or edit
System malfunction / User interface
Coil issue
Exam education (how to)
Other
Detailed Description of the Issue
*
The more detailed the better but leave out the Fluff!
Upload Images Relevant to Request
Upload a File
Drag and drop files here
Choose a file
Images are worth 1000 words
Cancel
of
Upload Relevant Files (Images, Reports, etc.)
Please press Submit when you are done. Everything below the Submit button is for the Imaging Diversified apps support team only. Please leave it blank.
Submit Support Request
For the Imaging Diversified apps support team only!!!!
Claimed by
First Name
Last Name
Support completed by Apps specialists
First Name
Last Name
Start Time
Hour Minutes
AM
PM
AM/PM Option
Time of completion
Hour Minutes
AM
PM
AM/PM Option
Completion date and time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Notes to Add on Issue/Resolution by Support Person
Should be Empty: