Request To Book an Event

EVENT SUPPORT REQUEST FORM
REQUESTOR INFORMATION
Company Name*
Division
Requestor*
Phone*
E-mail Address*
[email protected]
Start Date of Event*
MonthDayYear
Date
End Date of Event*
MonthDayYear
Date
Start Time of Lab:
Hour Minutes
AM/PM Option
End Time of Lab:
Hour Minutes
AM/PM Option
What type of support are you requesting?*
Equipment and RTsEquipment onlyRT staffing onlyEvent coordinationOther
FACILITY INFORMATION
Facility Name
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
What type of lab?*
Fixed location, i.e. in a buildingMobile lab, i.e. in a truck trailerOther
If the event is in a room with carpeting, do you have hard surface flooring to position under the C-arm equipment?
No, I need to request hard surface flooring from Kraft MedicalYes, I am providing hard surface flooringThe event space is all hard surface flooringOther
Type of Lab (Anatomy)*
On Site Contact Name*
On Site Contact Phone*

DELIVERY INFORMATION
DELIVERY INFORMATION
Please note that the date and time of delivery will be confirmed closer to the date of the event. We cannot guarantee your exact time requested.
Date of Delivery*
MonthDayYear
Date
Time of Delivery Requested*
Hour Minutes
AM/PM Option
Date of Pickup*
MonthDayYear
Date
Time of Pickup Requested*
Hour Minutes
AM/PM Option
Please verify that all loading areas, including elevator, are at least 64" x 54"*
I have verified all loading areasI am not sure of the loading areas' dimensions at this time
Delivery/Set up Instructions

EQUIPMENT INFORMATION
EQUIPMENT INFORMATION
Type of C-arm
Full-Size Ortho/generalFull-Size 12" Ortho/general (additional cost will apply)Full-Size Vasc (additional cost will apply)Full-Size 12" Vasc (additional cost will apply)MiniNone
Number of C-Arms
Number of Lead Aprons
(10 included with each full-size C-arm, 5 included with mini c-arm)
Number of Tables
Additional C-Arm needs?

RADIOLOGIC TECH (RT) INFORMATION
RADIOLOGIC TECH (RT) INFORMATION
1 RT included per full size C-arm (up to 6 hours), NO RT included with Mini C-arm
Number of Days for RTs
1234+
Day 1 - Number of Radiologic Technologists Requested
Day 1 - Start Time for RT(s)
Hour Minutes
AM/PM Option
Day 1 - End Time for RT(s)
Hour Minutes
AM/PM Option
Day 2 - Number of RTs Requested
Day 2 - Start Time for RT(s)
Hour Minutes
AM/PM Option
Day 2 - End Time for RT(s)
Hour Minutes
AM/PM Option
Day 3 - Number of RTs Requested
Day 3 - Start Time for RT(s)
Hour Minutes
AM/PM Option
Day 3 - End Time for RT(s)
Hour Minutes
AM/PM Option
Days 4+ RT Request Details
Other notes about RT request and times