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Onsite Preventative Maintanence Form
Save & Return
Use an account to return to saved work.
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Clinic Name
*
Address
*
Address 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
System
*
SmartDR 1417
SmartDr 1717
SmartDR Premier (Canon Panel w SmartDR Software)
cSeries (NE)
Next Equine DR
Sprint Bolt
Sprint Air
RLT
eSeries 1417
eSeries 1700
eSeries 1600
Canon CXDI
Other
Plate Serial Number
*
Software Serial Number
SmartDR Serial Number (SDN)
Panel Firmware
*
System
Computer Information
Acquisition Software Version
Acq Software Update Neeed
No
Yes
Acq Disk Space Total
Acq Disk Space Frere
Review Software Version
Review Software Update Neeed
No
Yes
Server Disk Space Total
Server Disk Space Free
Image Distribution Confirmed
Local Archive
AIS
Antech Imaging Services (AIS)
Antech Imaging Services User Information
www.antechimagingservices.com
AIS Username
AIS Password
Computer Notes:
X-Ray / Table Information
CHECK WITH TECH SUPPORT FOR PROPER GAIN CALIBRATION NUMBERS PRIOR TO CALIBRATING
1-800-819-5538
Gain Cal
Gain Cal KVP
Gain Cal mAs
X-ray Machine / Manufacture Date
X-ray Tube Date
X-Ray Notes:
PM Services
PM Service
Panel Centered and Aligned and recalibrate
Bucky Tray Secure - no loose parts, etc
Acquisition Computer/Screen Cleaned
Server Computer/screen Cleaned (if non-SmartPACS)
Touch Screen Calibrated (DELL ONLY)
Foot Pedal Cleaned
Physical Inspection
*
Equipment Inspection
1
2
3
4
5
Cable Status
1
2
3
4
5
Acquisition Computer
1
2
3
4
5
Server Computer
1
2
3
4
5
PM Notes / Actions
🛈
Service Notes
Service / Onsite Notes
Actions Taken Onsite
🛈
Image Upload
Image Upload
Image Upload
Image Upload
Image Upload
Image Upload
Image Upload
Image Upload
Image Upload
Image Upload
Follow Up Actions
Follow Up Actions
*
🛈
Signature
Sound Representative
*
Date
*
+
Sound Representative Signature
*
clear
Account Representative Info
Account Representative
Date
+
Email Address