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Please fill out the form below. (* indicates a required field, ** required if USA or Canada)

Select which Carestream Health product(s) you would like to receive information about.*
Business Diagnostics Medical Printing
CAD Solutions Oncology
Computed Radiography Orthopedics
Digital Radiography PACS/RIS
Digitizers Professional Services Storage Solutions
Film Imaging Storage Solutions
Mammography

Salutation
First Name*
Last Name*
Title
Facility Name*
Facility Address*
Address Line 2
City*
State/Province**
Country*
ZIP/Postal Code*
Phone Number
Fax Number
E-Mail


Which best describes your facility?
Hospital
Imaging Center / Clinics
Womens Health Center
Orthopedic Practice / Center
Cancer Center/Oncology Practice
Consultant/Project Management
College/Training Institution
Distributor/OEM/VAR
Other 


What is your job function?
Radiologist
Radiologist Administrator
Radiology Technician
Chief Radiologist
Chief Mammographer
Mammography Technician
PACS/RIS Manager
Hospital Administrator
Business Manager
IT Manager
MIS Director
Chief Information Officer
Purchasing/Materials Manager
 Other (specify) 


Which companies do you primarily work with?
Carestream Health / Kodak
Agfa
GE
Fuji
Konica
Philips
Siemens
 Other (specify) 


What best describes your role in purchasing?
Decision Maker
Recommend/Specify
Influence
Not Involved


How soon do you plan to purchase?
0-6 months
7-12 months
Over 12 months


Is your planned purchase funded or budgeted?
Funded
Budgeted
Under review/Seeking budget
Not sure


Would you like to receive future notice from Carestream Health about new products and special offers?
By E-mail
By Other Means
No Thanks


How can we be of further assistance?
Have a Rep call
Product Demo
Technical Assistance
Info only/Send literature

 
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