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

PrefixFirst NameLast Name
Callback Phone

Area CodePhone Number
Your E-mail
example@example.com
Dealer Company Information
Dealer Company Name*
Dealer Company Phone Number*

Area CodePhone Number
Dealer Website
ie. dealercompany.com
Accounts Payable Email
example@example.com
Dealer Company Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Practice (End-User) Information
Practice Name*
Practice Phone Number*

Area CodePhone Number
Practice Website
ie. footandankle.com
Accounts Payable Email
example@example.com
Practice Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Primary Doctor's Name

PrefixFirst NameLast NameSuffix
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 NameLast Name
Phone Number*

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

MonthDayYear
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)*

YesNoOther
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

Cancelof
Completed Installation Photo(s)

Browse Files

Cancelof
Should be Empty:

New Site Registration Form

Your Information

Dealer Company Information

Practice (End-User) Information

Installed Components