Cone Beam Shielding Plan Review Data Sheet

lifegunbarrelcityΠολεοδομικά Έργα

26 Νοε 2013 (πριν από 3 χρόνια και 7 μήνες)

102 εμφανίσεις





TM

C
one Beam

Shielding
Plan Review

Data Sheet


Facility Name
:







Facility Address (include city, state & zip code)
:







Facility Contact and T
itle
:







Contact Phone Number
:



Contact Fax Number or email:













Mailing Address (include city, state & zip code)
:









Cone Beam

Data

CONE BEAM MODEL
:


I
-
Cat Classic



I
-
Cat Platinum (17
-
19)


I
-
Cat Precise


Gendex

CB
-
500


Sirona
Galileos


Gendex GXDP 700


Instrumentarium OP300D


Soredex Scanora


Other







WORKLOAD:

iCat Classic:





scans per week @ 10 sec;





scans per week @ 20 sec


Platinum/
Precise/
CB
-
500:






scans per week @ 8.9 sec;





scans per week @ 26.9 sec


Sirona Galileos
:





scans per week


GXDP 700/OP300D:






Cone Beam Small FOV per week;





Cone Beam Large FOV per
week;





Pans per week;





Cephs per week


Soredex Scanora:





XL FOV;





Large FOV;





Medium FOV;





Small FOV;





Pans


Other:











Page
2

of
3


Interior wall

C
overings
(not the frame)
are made of :

1.

wood

(paneling)


gypsum

concrete

other (specify)







2. The thickness of the wall
material

is






inches.




Exterior wall
C
overings
(not the frame)
are made of :

1.

wood

(paneling)


gypsum

concrete

other (specify)







2. The thickness of the wall
material

is






inches.


Floor & Ceiling Information


Single story structure


ground below and sky above

the imaging room


Above Room

a. The space above is used as a







b. The distance from the floor of the imaging room to the floor above is







c.
The floor above is composed of







with a minimum thickness of






inches.




Below Room

a. The space below is used as a







b. The distance from the floor of the imaging room t
o the floor below is







c. The floor below is composed of






with a minimum thickness of






i
nches.



Room Drawing


must contain all of these elements
:


Lengt
h and width of the x
-
ray room (show the beginning and end of the measurement)


Proposed location of the control switch


The method the operator will
use to
view the patient during exposures

(window, mirror, video camera,

etc.)


Identify
all areas beyond the walls of the x
-
ray room


Proposed location
and orientation
of

the x
-
ray unit


Width of any
adjacent
corridors and the identity of areas beyond the corridors.


Ter
ms of Service

1.

A plan review report cannot be issued unless we have all information required to complete the report.

2.

All information submitted must be legible.

3.

ProPhysics Innovations is not responsible for obtaining or providing information being request
ed on
the application.

4.

Any additional information, not requested on the application, but incidental to the performance of the
service is subject to items 3
-
5 of these terms.

5.

The report is a recommendation only, based on industry standards and state regul
ation.

6.

Please contact our plan review department for
pricing.


Payment



Credit Card (Visa, MasterCard, American Express and Discover)

In order to accept payment via credit or debit card, we will need the following information:

Cardhol
der’s Name:






Page
3

of
3


Cardholder’s Billing Address:






City:






State:






Zip:






Credit Card Number:






Expiration Date:






/






Security Code:






3 digits on back for Visa, MC, Discover

4 digits on front for Amex



To make payment via telephone please call 800.835.3615


You may fax payment information to 919.651.1416


You may e
-
mail payment information t
o
admin@prophysics.com





Please forward the complete
d

form
and drawing(s)
to ProPhysics at
Planreview@ProPhysics.com

or fax (919)
651.1416
.