EXHIBIT 10.8
POSITRON EMISSION TOMOGRAPHY
MOBILE SERVICES AGREEMENT
This Agreement is entered into by MOBILE P.E.T SYSTEMS, INC., a Delaware
Corporation ("MOBILE PET"), with its principal place of business at 0000 Xxxxxxx
Xxxxxx Xxxxx, Xxx Xxxxx, Xxxxxxxxxx, 00000, and the following party:
-------------------
---------------
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("CLIENT"), with both MOBILE PET and Client collectively referred to as the
"PARTIES."
RECITALS
MOBILE PET desires to provide Mobile Positron Emission Tomography to Client and
Client desires to contract with MOBILE PET to utilize the Mobile Positron
Emission Tomography ("PET") System(s).
By this Agreement, MOBILE PET is only providing the use of a mobile PET imaging
unit and other services described in this Agreement. The technical personnel
necessary to operate such equipment shall be under the supervision of attending
physicians, and other services hereinafter described.
NOW, THEREFORE, in consideration for the mutual promises and convenants
contained herein, and for other good and valuable consideration, the Parties
agree as follows:
ARTICLE I
WARRANTIES
A. MOBILE PET will be the operator of a mobile PET system imaging unit
(the "UNIT,") and provide the services described in Article II.
B. Client desires to use MOBILE PET's imaging services and has those
physicians or medical specialists who are, or will become at the time
services are rendered by MOBILE PET, qualified to medically interpret
and report on PET imaging data.
C. Client has or will obtain all documents, approvals, licenses, and
certifications required for it to use the services provided by MOBILE
PET.
D. MOBILE PET has been duly incorporated and is validly existing as a
corporation in good standing under Delaware law and qualified as a
foreign corporation where required.
E. Client is a validly existing entity entitled to do business in
_________ and where required, or is properly licensed to conduct
business in __________ and where required.
ARTICLE II
SERVICES PROVIDED BY MOBILE PET
A. MOBILE PET will provide Client with PET imaging services on the following
terms and conditions:
1. UNIT DESCRIPTION. The Services shall include the use of the
Unit (a CTI/Siemens ECAT PET system) housed in a mobile coach
environment (collectively the "EQUIPMENT"), as further set
forth in SCHEDULE "A" attached to this Agreement. MOBILE PET
reserves the right to modify final specifications or accept
modifications imposed by the Equipment or the Coach
Manufacturer. Any such modification to the Unit or Equipment
shall not affect the obligations of the Parties under this
Agreement.
2. MINIMUM AVAILABLE IMAGING TIME. After the Commencement Date,
defined below, MOBILE PET shall be available to provide
services to Client pursuant to the specific terms of this
Agreement.
3. ADDITIONAL IMAGING TIME. MOBILE PET shall use its reasonable
best efforts to provide additional imaging time as required by
Client.
4. STAFFING. MOBILE PET shall provide, at its sole cost and
expense, one (1) trained PET technologist who will operate the
Unit. The number of technologists utilized shall be based on
volume of activity. If MOBILE PET, at its sole discretion,
extends the operating hours of the Unit to provide additional
imaging time, the staffing shall be increased accordingly. The
Unit will operate for a minimum of eight (8) hours per
contracted day, plus set-up time for the Unit. MOBILE PET will
train Clients qualified nuclear medicine technologist to
operate the Unit as is reasonable to do so without
interrupting daily PET exam schedules.
5. TRAINING. MOBILE PET shall provide initial training to
Client's physicians in the use of the Unit at a location to be
determined by MOBILE PET with Client's approval, which shall
not be unreasonably withheld or delayed. Client (or the
attending trainees) shall pay all costs for attending the
training and any additional training, including travel costs,
lodging and meals.
6. PATIENT LOG. MOBILE PET shall maintain a daily log of all
patients who receive PET scans while the Unit is stationed at
Client's site. This log shall be available for inspection by a
duly authorized representative(s) of Client on reasonable
notice to MOBILE PET during normal working hours of the Unit
at Client's site. All patient logs will be maintained for a
period of ninety (90) days on the mobile Unit. After the
initial ninety (90) days, all records will be stored and
notice for the request for records shall be served at MOBILE
PET's principal office.
7. POLICY AND PROCEDURES. MOBILE PET and Client shall mutually
agree upon and maintain a Policy and Procedures Manual on the
premises of the Unit and shall incorporate specific Client
procedures, including "Code Blue" and "Code Red" situations,
Disaster Drill Triage Exercises, and all other emergency
procedures as may arise during the course and scope of
Client's services to third-party patients.
8. SERVICE SCHEDULE. MOBILE PET shall provide Client with PET
equipment and technologist as indicated in SCHEDULE "A"
attached hereto. If either Party desires to change the
schedule, it shall provide the other party with fourteen (14)
days' written notice. If the Unit is inoperable on a scheduled
day of service to Client, MOBILE PET will use best efforts to
arrange a make-up day as required.
9. VALUE ADDED CUSTOMER SUPPORT PROGRAM. MOBILE PET shall provide
the following support services to assist Client in developing
a comprehensive PET program at NO ADDITIONAL COST to Client:
a. STRATEGIC MARKETING PROGRAM
1. Seminar by expert PET Radiologist to educate Clients
physicians on the benefits and indications of PET.
2. "Announcement of Service" letter to medical staff
from radiology and administration departments,
reinforcing the availability of PET service.
3. Mass mailing of marketing materials to all area
physicians on a quarterly basis for the first year of
service.
4. Provide "PET Patient Information Brochure" that will
answer many of the questions that patients ask when
scheduling PET exams
b. LICENSING AND PROTOCOL ASSISTANCE FOR HANDLING
RADIOPHARMACEUTICALS.
c. CONVENIENT AND TIMELY ACCESS TO RADIOPHARMACEUTICALS
THROUGH MOBILE PET'S GROUP PURCHASING AGREEMENT.
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d. TRAINING OF CLIENT'S BUSINESS OFFICE PERSONNEL IN PET
BILLING METHODOLOGY, CPT CODES, REIMBURSEMENT DATA AND
COLLECTION PROCEDURES.
ARTICLE III
SERVICES BY CLIENT
Client shall provide, at no cost or expense to MOBILE PET, the following
services, supplies, and facilities for use by MOBILE PET:
A. LOCATION; SITE PREPARATION. Suitable space for the Unit shall be
provided by Client, on a site which is under Client's ownership or
supervision and control, at which the Unit shall be stationed for
imaging purposes. This Site and all modifications to it shall be
subject to the written approval of MOBILE PET and the Equipment
Manufacturer, and it and the use of the Equipment on it as contemplated
by this Agreement shall comply with applicable law. Client will prepare
the site according to MOBILE PET's specifications and the terms and
conditions of this Agreement. MOBILE PET is not required to provide a
Unit at any site which MOBILE PET has not approved in writing. Client
shall pay all site preparation costs and complete this preparation
before MOBILE PET shall be required or obliged to provide services
under this Agreement.
B. POWER. Client shall supply suitable electric service and utility
service to operate the Unit. Electric service shall contain a
three-phase power source via lead-in cable on one dedicated power line
with 60 Hertz and 480 volts of power, located within a 25-foot radius
of the Equipment's imaging location.
C. TELEPHONE. The use of a telephone extension to permit personnel in the
Equipment to make and receive telephone calls and facilitate the
scheduling and movement of patients.
D. MEDICAL SUPPLIES. All necessary medical supplies as may from time to
time be, required to operate and utilize the Unit. Client will also
supply film and processing services.
E. MEDICAL SERVICES AND EMERGENCY CARE. Client shall provide the services
of all physicians, medical technologists and other personnel who are to
assist and care for Client's third-party patients. All such personnel
and medical staff shall be present when any third party patient is
located in or near the Equipment. Client shall provide all medical
supplies, facilities, personnel and physicians necessary to provide
patients with any required emergency care, including oxygen,
aspirator(s) and defrilbrillator(s) when deemed necessary.
F. LICENSING . Client shall provide copies of its contracted facilities
RADIO ACTIVE MATERIALS license and copies of physician(s) Nuclear
Medicine certification and any other pertinent information as may be
required by ________ or other health care regulating authorities.
ARTICLE IV
FEES PAID BY CLIENT TO MOBILE PET
A. FEES. The fees shall be paid in accordance with the terms and
conditions of this Agreement and as specified in SCHEDULE "C", attached
hereto.
B. FEE INCREASE. Basic charges shall remain as listed in the attached
Schedule(s) for the term of this Agreement, except for increases in the
cost of consumables or maintenance costs for the Unit. MOBILE PET shall
give Client one hundred and eighty (180) days' written notice of such
inflationary increases in charges.
C. BILLING AND PAYMENT TERMS. Client shall be billed monthly for PET
services and payment will be due within sixty (60) days after the month
in which the PET service was provided. Additional usage fees,
consumables and adjustments will be included on the monthly invoices as
incurred. Client shall pay MOBILE PET all fees when due. For accounts
not paid per above terms, Client shall pay a finance charge of one and
one-half percent (1.5%) per month on all balances outstanding over five
(5) days from the due date. Such finance charge shall be increased if
the Prime Rate, as stated in the WALL STREET JOURNAL, exceeds sixteen
percent (16%). MOBILE PET's right to collect fees properly invoiced to
Client shall not be subject to any right of set off, subrogation,
counter-claim or other action.
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ARTICLE V
TERM, RENEWAL AND TERMINATION
A. TERM. The initial term of this Agreement is five (5) years from the
Commencement Date.
B. SERVICE COMMENCEMENT. MOBILE PET anticipates the beginning of its
services to Client within thirty (30) days after Agreement completion
("COMMENCEMENT DATE") If MOBILE PET is unable to begin service as of
the Commencement Date, Client's obligation to pay any fees, and MOBILE
PET's obligation to provide services, shall be suspended until the Unit
or a comparable alternative system is delivered. This Agreement shall
remain in full force and effect during this period of suspension.
C. RENEWAL. This Agreement shall be automatically renewed unless either
Party shall, not less than ninety (90) days before the expiration of
the term, by registered or certified mail, return receipt requested,
notify the other of its intentions not to renew this Agreement.
D. TERMINATION.
1. Client shall have cause for termination of this Agreement for any
of the following reasons:
(a) If MOBILE PET defaults in the performance of any
material covenant or provision of this Agreement and
such default shall continue for a period of sixty
(60) days after written notice by certified mail,
return receipt requested, to MOBILE PET from Client
stating the specific default.
(b) If PET patient referral base does not provide Client
with an economic justification to continue this
Agreement, with a one hundred and eighty- (180) day
written notice.
(c) If Client elects to install a fixed site PET system,
Client may terminate this Agreement on not less than
one hundred and eighty (180) days prior written
notice to MOBILE PET, delivered to MOBILE PET by
registered or certified mail, return receipt
requested. In addition to the foregoing and as a
condition to Client's right to terminate this
Agreement pursuant to the preceding sentence, Client
shall notify MOBILE PET in writing within thirty (30)
days after Client makes election to install a fixed
site PET system. MOBILE PET shall have a right of
first refusal (for 30 days after receipt of written
notice from Client) for any joint venture or other
collaborative arrangement for a fixed site PET system
that Client wishes to enter.
(d) If MOBILE PET applies for or consent to the
appointment of a receiver, trustee or liquidation of
all or substantially all its assets, files a
voluntary petition in bankruptcy, or is unable to pay
its debts as they come due or make a general
assignment for the benefit of creditors to take
advantage of any insolvency law, or if an order,
judgment, or decree shall be entered by a court of
competent jurisdiction on the application of a
creditor, adjudicating MOBILE PET as bankrupt or
insolvent or approving a petition seeking
reorganization of MOBILE PET or appointing a
receiver, trustee or liquidation of all or a
substantially all MOBILE PET's assets.
2. MOBILE PET shall have cause for termination of this Agreement
for any of the following reasons:
(a) If Client shall default in the performance of any
material covenant or provision of this Agreement and
such default shall continue for a period of sixty
(60) days after written notice by certified mail,
return receipt requested, to Client from MOBILE PET
stating the specific default.
(b) If Client shall apply for or consent to the
appointment of a receiver, trustee or liquidation of
all or substantially all its assets, file a voluntary
petition in bankruptcy, or be unable to pay its debts
as they come due or make a general assignment for the
benefit of creditors to take advantage of any
insolvency law, or if an order, judgment, or decree
shall be entered by a court of competent jurisdiction
on the application of a creditor, adjudicating
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Client as bankrupt or insolvent or approving a
petition seeking reorganization of Client or
appointing a receiver, trustee or liquidation of all
or a substantially all Client's assets.
(c) If Client shall fail to make any payment to MOBILE
PET when due and does not make such payment within
ten (10) days after receiving written notice of such
failure from MOBILE PET.
ARTICLE VI
GENERAL PROVISIONS
A. MAINTENANCE AND OPERATIONS. MOBILE PET shall, at its sole cost and
expense, be responsible for the maintenance and operation of the Unit
pursuant to the Manufacturer's recommendations and service contract.
B. PRACTICE OF MEDICINE. Neither MOBILE PET, nor any of its personnel,
shall practice medicine or offer medical advice and/or opinions.
C. MOBILE PET INSURANCE. MOBILE PET shall, at its sole cost and expense,
maintain during the term of the Contract such fire, theft, general
liability and extended insurance coverage with respect to the operation
of the Unit as MOBILE PET deems appropriate or as required by the
Equipment Lender and shall comply with state and local regulatory
requirements. MOBILE PET will provide proof of insurance to Client
before commencement of operations.
D. CLIENT INSURANCE. Client represents and warrants that at all times
during the term of this Agreement, as it may continued from time to
time, Client shall maintain or cause to be maintained suitable general
and professional liability insurance coverage with respect to Client's
activities. All Client insurance shall name MOBILE PET as an additional
insured and shall provide MOBILE PET with thirty (30) days' written
notice before cancellation. Furthermore:
1. GENERAL LIABILITY. Client shall, at its own cost and expense,
during the term of this Agreement, maintain general public
liability insurance against loss arising by way of example and
not by way of limitation, bodily injury, death or damage to
property of others, insurance protection to the limit of not
less than One Million Dollars ($1,000,000.00) per occurrence
combined single limit or such greater amount as MOBILE PET
shall reasonably deem necessary and shall, as consistent with
industry practice, subject to the deductible or self-insurance
provisions which in the aggregate do not exceed Twenty-Five
Thousand ($25,000.00).
2. PROFESSIONAL LIABILITY. The clinicians who interpret and
report on the PET scans and supervise the technicians, and any
other physician who performs any medical services on a patient
while on board the Unit shall, at all times during the term of
this Agreement, as extended from time to time, maintain
suitable professional liability insurance with respect to
their activities. Physician shall provide MOBILE PET with a
copy of certification of insurance that evidences this
coverage.
E. AVAILABILITY OF UNIT. MOBILE PET warrants that the Unit will be
available for a minimum of eight (8) hours of diagnostic time per
contracted day, not including set-up time for the Unit. MOBILE PET will
make every reasonable effort to ensure that all equipment maintenance
occurs during non-contracted hours.
F. PERSONNEL. MOBILE PET will provide the PET technologists and other
personnel reasonable necessary to set-up and operate the Unit for the
purposes as specified in this Agreement. If Client is dissatisfied with
any of MOBILE PET on-site personnel, Client shall promptly notify
MOBILE PET in writing, setting forth the specific basis for Client's
dissatisfaction. On receipt of such notification, MOBILE PET will
promptly review the situation and take such action as MOBILE PET shall
reasonably determine to be necessary to remedy the difficulty;
provided, however, MOBILE PET at all times retains sole authority to
employ, terminate or discipline its personnel.
G. IMAGING QUALITY. MOBILE PET warrants that the Unit's imaging
performance during the term of this Agreement will meet or exceed the
performance as accepted by Client at the time of Service Commencement.
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H. INDEMNIFICATION AND HOLD HARMLESS. Each Party shall hold the other
harmless for the Party's acts, errors or omissions and those of their
respective agents, employees and/or guests, against all claims,
liabilities, damages, losses, fees (including attorneys' fees), costs,
and litigation arising from the representations by or conduct of one
party to the other.
I. FORCE MAJEURE. MOBILE PET's failure to perform under this Agreement
will be excused because of any delay or prevention, directly or
indirectly, caused by any condition beyond MOBILE PET's control,
including: fires; floods; earthquakes; snow; disasters; other acts of
God; accidents; riots; wars; operation of law; strikes; governmental
action or regulation; shortage of labor, fuel, power, materials,
supplies or transportation; or supplier delay.
J. EXCLUSIVITY. Throughout the term of this Agreement, all PET services
performed on Client's site shall be performed exclusively by MOBILE
PET. If Client utilizes other PET services in violation of Article VI,
Section J., MOBILE PET shall be reimbursed by Client for each PET study
performed by such third party PET service in accordance with the terms
and set forth in exhibit C.
K. RIGHT OF FIRST REFUSAL. If Client identifies an opportunity to develop
a fixed site PET system installation at one of its site locations,
MOBILE PET shall have the right to participate as part owner in said
opportunity, at its sole discretion
L. CONFIDENTIALITY. All information regarding MOBILE PET's customer
support programs, contract terms and conditions shall be considered
confidential and is intended only for those individuals within Clients
organization who are authorized to access it for purposes economic and
clinical evaluation of the Agreement.
M. NON-SOLICITATION OF MOBILE PET'S EMPLOYEES. Client shall not attempt
to hire away, employ or in any other manner retain the services of
MOBILE PET's employees in any capacity whatsoever without the prior
written consent of MOBILE PET.
N. AUTHORIZATION. This Agreement has been duly authorized, executed,
and/or delivered by and on behalf of the Parties.
O. NOTICES. Except as otherwise provided in this Agreement, any notice or
other communication required or permitted by any provision of this
Agreement shall be in writing and shall be deemed to have been given or
served for all purposes if delivered personally, or sent by registered
or certified mail, return receipt requested, postage prepaid, addressed
to the Parties as follows:
To MOBILE PET: MOBILE PET SYSTEMS, INC.
0000 Xxxxxxx Xxxxxx Xxxxx, Xxxxx 000
Xxx Xxxxx, Xxxxxxxxxx 00000
With copy to:
Xxxx Xxxx Xxxxx, Esq.
Xxxxxxx & Xxxxxxxx, A.P.C.
00000 Xx Xxxxxx Xxxx, Xxxxx 000
Xxx Xxxxx, XX 00000
To Client: _______________________
_________________
_________________
P. VENUE AND CHOICE OF LAW. This Agreement shall be governed and
interpreted under California law. The venue for any and all disputes
arising under this Agreement shall be the County of San Diego.
Q. ASSIGNMENT. This Agreement may not be assigned by Client to any third
party without MOBILE PET's express written consent, which may be
withheld in its sole discretion. If such consent is given, MOBILE PET
may require reimbursement for reasonable costs associated with such an
assignment.
R. ACCESS TO BOOKS AND RECORDS. MOBILE PET shall make this Agreement and
its books, documents, and records available to the Secretary of Health
and Human Services, to the Comptroller General, or to their
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duly authorized representatives to the extent required by Section 952
of the Omnibus Budget Reconciliation Act of 1980.
S. VALIDITY AND BINDING, COMPLETE AGREEMENT. The validity and
enforceability of any provision of this Agreement shall in no way
affect the validity or enforceability of any other provision herein.
This Agreement sets forth the entire understanding of the Parties and
supersedes all prior or contemporaneous oral or written agreements,
understandings, arrangements, negotiations or communications between
the Parties. This Agreement shall be binding on and inure to the
benefit of the Parties' successors, heirs, and assignees.
T. AMENDMENTS. This Agreement shall not be modified or amended except on
the written agreement of the Parties.
U. ATTORNEYS' FEES AND COSTS. If it is necessary to enforce or interpret
the terms and conditions of this Agreement, the prevailing party to any
judicial proceeding or arbitration shall be entitled to all attorneys'
fees, costs of suit, and expenses therein, in addition to any other
relief to which such party is entitled.
V. INTERPRETATION. As the context requires, any gender includes all
others, the singular number includes the plural, and vice-versa.
Captions are inserted for convenience of reference and do not describe
or limit the scope or intent of this Agreement. Any recitals above, and
any exhibits or schedules referred to and/or attached hereto, are
incorporated by reference into this Agreement. "PERSON" includes any
legal entity. "INCLUDING" means including without limitation. No
inference, assumption or presumption shall be drawn if a party or a
party's attorney prepared and/or drafted this Agreement; it shall be
conclusively presumed that the parties participated equally in its
preparation and/or drafting. This Agreement may be executed in
counterparts, each of which shall be deemed an original. An executed
counterpart of this Agreement transmitted by fax shall be equally as
effective as a manually executed counterpart. Each party shall take all
reasonable steps, and execute, acknowledge and deliver all further
instruments necessary or expedient to implement this Agreement.
We, the undersigned Parties, and each of them, have executed this Agreement and
agree to be bound by its terms and conditions.
MOBILE PET:
MOBILE P.E.T. SYSTEMS, INC.
A Delaware Corporation
___________________________________ Date:_____________________
By:
Client:
______________________________________
_____________________
___________________________________ Date:_____________________
By:
SCHEDULES:
"A": The Equipment & Service Schedule
"B": Patient Information/Authorization Sheet
"C": Compensation
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SCHEDULE A
1. SYSTEM DESCRIPTION
The ECAT-Registered Trademark- EXACT-TM- is a whole-body positron emission
tomography system providing volume measurements of metabolic and
physiologic processes.
The system includes the ECAT EXACT tomograph, an integrated workstation, 3D
Advanced Computational System (ACS II), and the patient handling system.
The tomograph field of view is 16.2 cm (6.38 in.) with 47 image planes.
Simultaneous acquisition, image reconstruction, processing, and data
analysis can be performed to generate high patient throughput and prompt
results.
2. DETECTOR ASSEMBLY
Detector Material Bismuth Germanate
Crystal Dimension 6.75mm x 6.75mm x 20mm deep (0.27in. x 0.27in. x 0.79in)
Crystal per Detector Block 64
Photomultiplier Tubes 4 per block
Detector Ring Diameter 824mm (32.4 in.)
Number of Detector Rings 24
Total Number of Detectors 9,216
Axial Field of Vision 162mm (6.38 in.)
Number of Contiguous Image Planes 47
Plane Spacing 3.375mm (0.133 in.)
3. DATA ACQUISITION/PROCESSING
Coincidence Time Resolution -6 nsec
Coincidence Window 12 nsec (prompt and delayed window)
Acquisition Modes Static, Dynamic and Gated (option)
Reconstruction Time 128 x 128 Matrix 2D less than2 min/frame (47 slices)*
3D less than7 min/frame (47 slices)**
4D less than10 min/frame (47 slices)***
Reconstruction Filters Xxxxx-Xxxxx, Hanning, Hamming, Parzen, Ramp,
Butterworth
* INCLUDES CORRECTIONS FOR NORMALIZATION, DEADTIME, ATTENUATION, SCATTER
AND DECAY.
** USING PROMIS RECONSTRUCTION AND INCLUDING CORRECTIONS FOR NORMALIZATION,
DEADTIME, ATTENUATION, AND DECAY.
*** INCLUDES 3D MODEL-BASED SCATTER CORRECTION.
4. PERFORMANCE SPECIFICATION
The following represent average performance values measured in accordance
with NEMA Standards Publication Nu-2 1994, PERFORMANCE MEASUREMENTS OF
POSITRON EMISSION TOMOGRAPHS. Acceptance specifications may vary.
PARAMETER 2D 3D
--------- -- --
Transaxial Resolution
FWHM at 1 cm 6.0 mm 6.0 mm
FWHM at 10 cm 6.7 mm 6.7 mm
Axial Resolution
FWHM at 0 cm 4.5 mm 4.6 mm
FWHM at 10 cm 5.9 mm 6.5 mm
Sensitivity @ 350 keV 180 kcps/muCi/cc 780 kcps/muCi/cc
UNIFORMITY LESS THAN 10% LESS THAN 10%
---------- ------------- -------------
County Rate Correction plus or minus5% up to 3.0muCi/cc plus or minus5% up to 0.5muCi/cc
(111 kBq/cc) (18.5 kBq/cc)
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Schedule A
Page Two(2)
5. GANTRY/PATIENT BED
Patient Port Diameter 562 mm (22.1in.)
Patient Couch Patient bed with full-body horizontal scan
range of 195 cm (76.8in.) and vertical
travel from 57 mm (22in.) to 93 cm
(37in.). Low attenuation head holder.
Maximum patient 158 kg (350lb.).
Patient Alignment Nine laser lines
define field of view for
precise patient
positioning.
Transmission Source Three retractable, self-storing rod sources.
Septa Motorized retractable septa enabling 2D or
3D acquisition.
Gantry Cooling Chilled water for maximum detector stability
and quiet patient environment.
6. DATA MANAGEMENT
Data Storage 2.0 Gbyte acquisition disk and DAT
drive for archiving sinogram data.
Acquisition Processor 3D ACS II with SPARC-Registered Trademark- CPU,
four 80 MFLOP array processors and 64 Mbyte
real-time sorter memory.
Operator's Console Integrated workstation with 1.0 Gbyte internal disk.
Communications Ethernet with TCP/IP protocols.
Video Display 41 cm (16in.) 1152 x 900-pixel color display.
Patient Data Storage 2.6 Gbyte erasable optical disk.
Laser Printer Black and white, 600 dpi.
7. ELECTRICAL REQUIREMENTS
Electrical Service 480 VAC//3 Phase//85KVA fused at 100 Amps
Electrical Customer Receptacle Xxxxxxx Xxxxx #DF2504FRAB
Configuration Three phase, 5 wire, 3 phases, neutral & 1 ground.
Frequency 60 Hz
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SCHEDULE B
PATIENT INFORMATION
----------------------------------------------------------------------------------------------------------------------
Patient Name _____________________________ Appointment Date ____________ Time: _________A.M. P.M.
Age: _________ DOB: ____________ M _____ F _____ Height _______ Weight _______ Dexterity: Left ____ Right ____
Referring Physician(s): ______________________________________________________________________________________________
Insurance Carrier: __________________________ Policy ID#: _____________________________________________________
CLINICAL DATA
List Previous Operations:
/X/ ______________________________________ Date: ___________ What Body Region? ________________________________
/X/ ______________________________________ Date: ___________ What Body Region? ________________________________
Have you had Radiation Therapy? ______Yes ______No
If Yes, please describe:
/X/ ______________________________________ Date: ___________ What Body Region? ________________________________
/X/ ______________________________________ Date: ___________ What Body Region? ________________________________
Have you had Chemotherapy? ______Yes ______No
If Yes, please describe:
/X/ ______________________________________ Date: ___________ Drug: ____________________________________________
/X/ ______________________________________ Date: ___________ Drug: ____________________________________________
Are you Diabetic: ______Yes ______No
If Yes, please describe Insulin therapy:
/X/ Date: ___________ Drug: ____________________________________________________________________________________
/X/ Date: ___________ Drug: ____________________________________________________________________________________
Have you had Vaccine Therapy: ______Yes ______No
If yes, please describe:
/X/ Date: ___________ Injection Site: __________________________________________________________
/X/ Date: ___________ Injection Site: __________________________________________________________
Date of last Vaccination: _______________________________________________________________________________________
Do you have:
Colostomys? ______Yes ______No If yes, describe location: _____________________________________________
Ileostomy? ______Yes ______No If yes, describe location: _____________________________________________
Indwelling/External Catheters? ______Yes ______No
Drains/Open Wounds? ______Yes ______No
Present Infections? ______Yes ______No If yes, describe: ___________________________________________
Artificial joints or implants? ______Yes ______No If yes, describe: ________________________________
Have you had any recent injuries? ______Yes ______No
If yes, please describe:
/X/ ______________________________________ Date: ___________ What Body Region? ________________________________
/X/ ______________________________________ Date: ___________ What Body Region? ________________________________
Are you Pregnant? ______Yes ______No
Have you consumed any liquids or food today? ______Yes ______No
If yes, please describe:
/X/ ______________________________________ Time: _______________________________________________________________
/X/ ______________________________________ Time: _______________________________________________________________
Have you used any chewing gum today? ______Yes ______No
I do hereby testify that the foregoing information is true and accurate to the
best of my knowledge.
Signed: ________________________________________ Date: ___________________________________________________________
Witness: ________________________________________ Date: ___________________________________________________________
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SCHEDULE C
(CONFIDENTIAL)
SCHEDULED SERVICE DAYS:
ONE day per WEEK
FEES: FEE FOR SERVICE SCHEDULE
First Four (4) PET Exams per day of service ---
$_______ per Exam
Next Four (4) PET Exams per day of service ---
$_______ per Exam
Additional PET Exams per day of service ---------
$______ per Exam
A minimum of four (4) exams per day of service is
required.
** Minimum per day will be waived for the first
_______(___) days that Contract is in effect.
Above prices include FDG.
DEPOSIT: SECURITY DEPOSIT
Client shall provide to MOBILE PET a ____________
security deposit based upon the required number of
days
By:__________________________________ Date:_________________
For:_________________________________
By:__________________________________ Date:_________________
For: Mobile P.E.T Systems, Inc.
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