Professional Services
Site Survey

Please complete and submit a new form for each service location.
Customer Information
Customer Name: * Customer ID:
Primary Contact: Aternate Contact:
Name: * Name:
Title: Title:
Phone: * Phone:
Mobile: Mobile:
E-mail: * E-mail:


Service Location
Location Name: * Service Level: *
Location Address: * Billing Address: *
Products to be serviced purchased from Richardson Electronics, Ltd: *
Manufacturer of display(s) covered under service contract: (Check all that apply)
Image Systems    NEC     Planar    Siemens    Other:
Calibration/Validation photometer currently at location: (Check all that apply)
Image Systems    NEC     Planar    Siemens    Other:
Calibration software in use at location: (Check all that apply)
Image Systems (CFS)  NEC (GammaComp MD)  Planar (CXtra)  Siemens (SMFit Act)
Other:


Read Room / Office Environment
Number of Workstations:   Display Type: Color Grayscale Both

Typical Configuration: (Check all that apply)
  1MP 2MP 3MP 4MP 5MP Mammography
  Single Head Dual Head Quad Head with Navigation / Work-List Display
  Desktop Cart Wall Mount Pole Mount Boom Mount
 

Emergency Room Environment
Number of Workstations:   Display Type: Color Grayscale Both

Typical Configuration: (Check all that apply)
  1MP 2MP 3MP 4MP 5MP Mammography
  Single Head Dual Head Quad Head with Navigation / Work-List Display
  Desktop Cart Wall Mount Pole Mount Boom Mount
 

Operating Room Environment
Number of Workstations:   Display Type: Color Grayscale Both

Typical Configuration: (Check all that apply)
  1MP 2MP 3MP 4MP 5MP Mammography
  Single Head Dual Head Quad Head with Navigation / Work-List Display
  Desktop Cart Wall Mount Pole Mount Boom Mount