RSNA 2007
November 25-30,
Chicago, Illinois
McCormick Place
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Required fields are marked with a (*).

Please fill out as much of the form as possible

First Name *

Last Name *

Email Address *

Title

Company *

Address *

Address 2

City *

State/Province *

Zip/Postal Code *

Country *

Work Phone *

Home Phone

Fax Number

Please Describe your type of business. Are you a hospital, teleradiology group, full center service, single-site, multi-site?

Number of full center/hospital location (Full center is a center for which we will do full flow including scheduling)
*
Are Centers in the Same City? - Yes / No
Comments:

Total Volume for full facilities

Number of read-only/over-read/external read locations
*
Are Centers in the Same City? - Yes / No
Comments:

Total volume for read-only facilities

Do you intend to share the data with all your centers? Describe how you plan to share data, single database, multiple databases, which data should be shared?
Yes / No Central Scheduling? Yes / No

Do you intend to have one central RIS? We can provide a centralized or distributed model; we can discuss the best model for your project. Please describe your environment.
Yes / No

Number of total procedures per year (List per center - C1 is center 1 for example) This number is critical for a budgetary quote.
C1:* C2: C3: C4: C5: C6:
C7: C8: C9: C10: C11: C12:
C13: C14: C15: C16: C17: C18:
Total for all centers: *
Total Number of Images on PACS:
Volume per year (TB):

Number of radiologists per center (Include people working from home) (Dictation software and hardware is licensed by workstation and not by radiologist) Voice Recognition is licensed by Radiologist.
C1: C2: C3: C4: C5: C6:
C7: C8: C9: C10: C11: C12:
C13: C14: C15: C16: C17: C18:
Total: Central Dictation? Yes / No
Total Number of Reading Workstations:
From Home:

Number of total transcriptionists (Include people working from home) (Transcription software and hardware is licensed by workstation and not by transcriptionist)
C1: C2: C3: C4: C5: C6:
C7: C8: C9: C10: C11: C12:
C13: C14: C15: C16: C17: C18:
Total: Central Transcription? Yes / No
Total Number of Transcription Workstations:
From Home:

Number of total staff per location (approximately) (List per center) This value is important to plan for the right number of trainers and time for deployment.
C1: C2: C3: C4: C5: C6:
C7: C8: C9: C10: C11: C12:
C13: C14: C15: C16: C17: C18:
Total:

MRI
How Many?
DICOM Worklist Compatible? Yes / No

CT
How Many?
DICOM Worklist Compatible? Yes / No

US
How Many?
DICOM Worklist Compatible? Yes / No

XRAY (CR)
How Many?
DICOM Worklist Compatible? Yes / No

NM
How Many?
DICOM Worklist Compatible? Yes / No

PET
How Many?
DICOM Worklist Compatible? Yes / No

FLOURO
How Many?
DICOM Worklist Compatible? Yes / No

DEXA/BD
How Many?
DICOM Worklist Compatible? Yes / No

Mammography

Need Mammo Tracking Module
How Many?
DICOM Worklist Compatible? Yes / No
Yes / No

List other modalities used

Need DICOM Worklist Manager?
Yes / No
For how many modalities? (Very important to know number of nodes that support this)

Need to track film checkout with barcode capability?
Yes / No

Need to track film release?
Yes / No

Do you have a RIS?
Yes / No Which RIS?

Need to integrate other RIS? Describe Integration
Yes / No
How?

Do you have a HIS?
Yes / No Which HIS?

Need to integrate HIS? Describe Integration
Yes / No
How?

Do you have a PACS?
Yes / No Which PACS?

Need to integrate PACS? Describe Integration
Yes / No
How?

Do you have a Billing System?
Yes / No Which System?

Need to integrate with Billing? Describe Integration
Yes / No
How?

Do you need a billing module?
Yes / No
Centralized Billing for Multi-center? Yes / No
Describe Billing Process

Need any other integrations? Describe.

Please describe your current dictation method.

Please describe your current transcription method.

Would you like to dictate over the Internet?
Yes / No From Home? Yes / No

Would you like to transcribe over the Internet?
Yes / No From Home? Yes / No

How are your reports and images distributed now?

Will you be using voice recognition?
Yes / No Preferred Company?

Will you be sharing reports with Ref. Physicians over the Internet? How about images?
Yes / No
How about images? Yes / No

Will you auto distribute reports?
Yes / No
Auto Fax Yes / No
Auto Print Yes / No
Auto Email Notification Yes / No
Other:

Do you need access to RIS functions through a PDA?
Yes / No

Do you need access to RIS functions through a PC Tablet?
Yes / No

Would you like to capture patient documents digitally via scanner?
Yes / No

Would you need to print any labels? Describe label use.
Yes / No

Would you like to capture patient documents digitally via digital forms?
Yes / No
How many digital forms will you have?

Do you have a technical support person or company?
Yes / No

Referred By

Have sales rep call?
Yes / No

Intend to buy In
months

Website
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Comments