Survey Form | tkxray

First Name

Last Name

Doctor Cell

Lead Shielding Plan Needed? Required

Yes

Clinic/ Facility Name

State Facility Number

Clinic Phone

Mailing Address

City

State

Postal / Zip code

Chiropractic Focus/Method

Coach/Coaching affiliation:

Contractor Contact Name

Contractor Phone

Expected Completion Date required

Clinic Address

City

State

Postal / Zip code

Check if address different for clinic.

Superintendent Contact Name

Superintendent Phone

Requested Equipment

Equipment currently installed (if any)

Number of days open per Week

Anticipated Maximum # of Patients per day (X-Ray)

Requesting Quote

Where did you hear about us?

X-Ray Room Layout (Upload)

Upload File

Upload supported file (Max 15MB)

Room Layout Requirements:

North shown on design
All dimensions of each wall
Any doors and windows shown
Dimensions of windows and door
Is it a single story building or not?
If multiple story, what is directly above and below? What material used for floor/roof?
Listed what is on the other side of each wall.
List any walls that are exterior and what is outside that wall as well.

Provided Room Layout Requirements:

Thanks for Submitting!   Our Sales team will get back to you with next steps.