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") and CLIENT NAME ("Client") signing below. Mobile PET
and Client are collectively referred to as the "PARTIES." Mobile PET desires to
provide Mobile Positron Emission Tomography ("PET") to Client and Client desires
to contract with Mobile PET to utilize its PET System(s). By this Agreement,
Mobile PET is only providing the use of a PET imaging system (a state-of-the-art
PET imaging system) (the "SYSTEM") and other services described in this
Agreement. Now, therefore, in consideration for the mutual promises and
covenants contained herein, and for other good and valuable consideration, the
Parties agree as follows:
1. WARRANTIES. Both Parties have or will obtain all documents, approvals,
licenses and certifications required for them to use the Services provided by
Mobile PET.
1.1. Mobile PET is a publicly traded corporation in good standing
under Delaware law and qualified as a foreign corporation where required by this
Agreement. Mobile PET will be the operator of the System and provide the
services described in Section 2.
1.2. 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.
2. MOBILE PET'S SERVICES. Mobile PET will provide Client with PET imaging
services ("SERVICES") on the following terms and conditions. Neither Mobile PET,
nor any of its personnel, shall be required to practice medicine or offer
medical advice and/or opinions
2.1. SYSTEM. The Services shall include the use of the System
housed in a mobile environment (collectively the "EQUIPMENT"), described in
SCHEDULE "A" hereto. Mobile PET reserves the right to modify final
specifications or accept modifications imposed by the Equipment or the Coach
manufacturer. Any such modification shall not affect the Parties' obligations
under this Agreement.
2.2. IMAGING TIME; AVAILABILITY. During the term of this Agreement
(the "TERM"), Mobile PET shall provide the Services to Client pursuant to this
Agreement. Mobile PET shall use its reasonable best efforts to provide
additional imaging time as Client reasonably requires.
2.3. STAFFING. Mobile PET will provide a PET technologist and
other personnel reasonably necessary, in its discretion, to operate the System
for the purposes of this Agreement. If Mobile PET, in its sole discretion,
extends the System's operating hours to provide additional imaging time, it may
increase the staffing accordingly. The System will be available for a minimum of
eight (8) hours per contracted day. If Client is dissatisfied with 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 this
notice, Mobile PET will promptly review the matter and take any action it
reasonably deems necessary, provided, Mobile PET at all times retains sole
authority regarding its personnel.
2.4. TRAINING. Mobile PET may arrange initial training for
Client's physicians in the use of the System. Training will occur at a site
coordinated by Mobile PET and the Equipment Manufacturer. Client (or the
attending trainees) shall pay all costs of attending this and any additional
training, including travel costs, lodging and meals.
2.5. PATIENT LOG. Mobile PET shall maintain a daily log of all
patients receiving PET scans while the System is stationed at Client's site.
Client's authorized representative may inspect this log on reasonable notice to
Mobile PET during normal working hours of the System at Client's site. Mobile
PET shall maintain all patient logs for ninety (90) days on the System;
afterwards, all records will be stored at Mobile PET's office.
2.6. POLICY AND PROCEDURES. Mobile PET and Client shall mutually
agree on and maintain a Policy and Procedures Manual on the premises of the
System 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 patients.
2.7. SERVICE SCHEDULE. If either Party desires to change this
service schedule of on-site days established by Mobile PET from time to time, it
shall provide the other Party with fourteen (14) days written notice. If the
System is inoperable on a scheduled day of service to Client, Mobile PET will
use best efforts to arrange a make-up day as the System's availability permits.
2.8. VALUE-ADDED CUSTOMER SUPPORT. Mobile PET shall provide
support services described on SCHEDULE "B" hereto to assist Client in developing
a comprehensive PET program at no additional cost to Client:
2.9. MAINTENANCE; OPERATIONS. Mobile PET shall: (a) at its
expense, be responsible for the maintenance and operation of the System pursuant
to the Manufacturer's recommendations and service contract, and (b) make every
reasonable effort to ensure that Equipment maintenance occurs during off-hours.
2.10. MOBILE PET INSURANCE. Mobile PET shall, at its expense,
maintain during the Term such general and professional liability insurance
coverage as described on SCHEDULE "C" hereto.
3. CLIENT'S SERVICES. Client shall provide, at its expense, the following
services, supplies and facilities for use by Mobile PET:
3.1. LOCATION; SITE PREPARATION. Client shall provide suitable
space for the Equipment on a site under Client's ownership or supervision and
control, at which the Equipment shall be stationed. This site and all
modifications shall be subject to Mobile PET's and the Equipment Manufacturer's
written approval and specifications, including Mobile PET's Site Planning Guide,
and shall comply with applicable law. Client shall, at its expense, complete all
site preparation before Mobile PET shall be required to provide its Services.
3.2. UTILITIES. Client, at its expense, shall supply suitable
electric and utility service to operate the System, including full phone
service.
3.3. MEDICAL SUPPLIES/SERVICES. Client shall provide: (a) all
necessary medical supplies and film as may from time to time be required to
perform the PET procedures (including FDG); (b) the services of all physicians,
medical technologists and other personnel who are to assist and care for
Client's patients (Mobile PET performs only the imaging procedure; Client
performs all other services, including patient preparation); and (c) all
required medical supplies, facilities, personnel and physicians necessary to
provide patients with any required emergency care, including oxygen,
aspirator(s) and defibrillator(s) when deemed necessary. All required personnel
and medical staff shall be available during imaging procedures. Client shall
provide copies of its radioactive materials license and physician(s) Nuclear
Medicine certification as may be required by health care regulating authorities.
3.4. PATIENT SCREENING. Client shall screen all patients for
suitability and safety during the System's use Client shall ensure that each
patient who arrives at the System has in his/her possession an adequate written
authorization to perform the PET imaging, if required, a History & Profile in
the form of SCHEDULE "D" hereto and such other forms or data reasonably required
by Mobile PET or Client's Policies and Procedures.
3.5. CLIENT INSURANCE. Client shall maintain suitable general and
professional liability insurance coverage for 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. Client's
general public liability insurance against loss arising from, for example,
bodily injury, death or property damage, shall have a limit of not less than
$1,000,000.00 per occurrence combined single limit or such greater amount as
Mobile PET reasonably deems necessary and shall, consistent with industry
practice, be subject to a deductible or self-insurance of no more than
$25,000.00. The clinicians who interpret and report on the PET scans and
supervise the technicians, and any
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other physician who performs any medical services on a patient while on board
the System shall, at all times during the Term maintain suitable professional
liability insurance. Client shall at all times provide Mobile PET with a current
copy of certification of insurance evidencing all coverages.
4. FEES. Client shall pay Mobile PET the fees specified in SCHEDULE "E".
Basic charges shall remain as listed in this SCHEDULE "E" for the Term, except
for increases in the cost of consumables or maintenance costs for the System.
Mobile PET shall give Client six (6) months' written notice of such inflationary
increases in charges. Client shall be billed monthly for PET Services, with
payment to be received by Mobile PET within thirty (30) 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 timely paid, 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 by the extent the Prime Rate, 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 setoff, subrogation,
counter-claim or other action.
5. TERM, RENEWAL AND TERMINATION. The initial Term is five (5) years from
the Commencement Date. Mobile PET anticipates the Services to begin within
thirty (30) days (the "COMMENCEMENT DATE") after execution of this Agreement. 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 System or a comparable alternative system is
delivered. This Agreement shall remain in effect during this suspension.
5.1. RENEWAL. This Agreement shall be automatically renewed for
additional Term(s) of five (5) years unless either Party, not less than six (6)
months before the Term (including any additional Term) expires, notifies the
other in writing of its intention not to renew.
5.2. TERMINATION BY CLIENT. Client shall have cause to terminate
this Agreement for any of the following:
5.2.1. If Mobile PET defaults in the performance of any
material provision of this Agreement and such default continues for sixty (60)
days after written notice to Mobile PET from Client stating the specific
default.
5.2.2. If Client elects to install a fixed-site PET system,
Client may terminate this Agreement on not less than six (6) months' prior
written notice to Mobile PET. As a condition to Client's right to so terminate
this Agreement, Client shall notify Mobile PET in writing within thirty (30)
days after Client elects 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 proposed by Client.
5.2.3. If Mobile PET applies for or consents to the
appointment of a receiver, trustee or liquidation of all or substantially all
its assets, files a voluntary petition in bankruptcy, is unable to pay its debts
as they come due, or if an involuntary bankruptcy petition is not dismissed
within ninety (90) days after its filing.
5.3. TERMINATION BY MOBILE PET. Mobile PET shall have cause to
terminate this Agreement for any of the following:
5.3.1. If Client defaults in the performance of any material
covenant or provision of this Agreement and such default continues for sixty
(60) days after written notice to Client from Mobile PET stating the specific
default.
5.3.2. If Client applies for or consents to the appointment
of a receiver, trustee or liquidation of all or substantially all its assets,
files a voluntary petition in bankruptcy, is unable to pay its debts as they
come due, or if an involuntary bankruptcy petition is not dismissed within
ninety (90) days after its filing.
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5.3.3. If Client fails 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.
6. GENERAL PROVISIONS.
6.1. INDEMNITY. Each Party shall hold the other harmless for the
Party's acts, errors or omissions and those of its agents, employees and/or
guests, against all claims, suits, liabilities, damages, losses, fees (including
attorneys' fees) and costs arising from the negligence, misconduct or breach of
this Agreement by the Party.
6.2. 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 its control, including fires, floods,
earthquakes, weather, 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.
6.3. EXCLUSIVITY. During the Term, all PET Services performed on
Client's site shall be performed exclusively by Mobile PET. If Client utilizes
other PET services, Client shall reimburse Mobile PET for each PET study
performed by such third party PET service in accordance with SCHEDULE "E".
6.4. CONFIDENTIALITY. All information regarding Mobile PET's
Services, customer support programs and/or this Agreement shall be considered
confidential and is intended only for those individuals within Client's
organization who are authorized to access it for purposes of economic and
clinical evaluation.
6.5. 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 Mobile PET's prior
written consent.
6.6. AUTHORITY. This Agreement has been duly authorized, executed,
and/or delivered by and on behalf of the Parties.
6.7. NOTICES. Except as otherwise provided in this Agreement, any
notice or other communication required or permitted by 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 set forth below. No
notice delivered to Client at the site shall be effective for purposes of this
Agreement.
To Mobile PET: MOBILE PET SYSTEMS, INC. With copy to: Xxxx Xxxx Xxxxx, Esq.
0000 Xxxxxxx Xxxxxx Xxxxx, Xxxxx 000 00000 Xxxxx Xxx Xxx #000
Xxx Xxxxx, Xxxxxxxxxx 00000 Xxx Xxx, XX 00000
To Client: CLIENT NAME
Client Address
City, State, Zip
6.8. VENUE; GOVERNING LAW; ATTORNEYS' FEES. This Agreement shall
be governed by California law. Venue for all disputes arising under this
Agreement shall be in San Diego County, California. The prevailing party in any
litigation or arbitration arising hereunder shall be entitled to all attorneys'
fees, costs of suit, and expenses therein, in addition to any other relief to
which it is entitled.
6.9. ASSIGNMENT. Client shall not assign this Agreement to any
third party without Mobile PET's express written consent, which may not be
unreasonably withheld. Client shall pay Mobile PET its reasonable costs
associated with such a request.
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6.10. ACCESS TO RECORDS. Mobile PET shall make this Agreement and
its books, documents and records available to the Secretary of Health and Human
Services, the Comptroller General or their duly authorized representatives to
the extent required by Section 952 of the Omnibus Budget Reconciliation Act of
1980.
6.11. INTERPRETATION. 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 regarding its subject matter 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. This Agreement shall not be modified or amended except on the
written agreement of the Parties. 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 exhibit or schedules
referred to and/or attached hereto (including the Site Planning Guide), 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 its 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.
Intending to be legally bound, the Parties have signed this Agreement as
of the date set forth below. By signing below, Client acknowledges receipt a
signed counterpart of this Agreement, all Schedules listed below, and Mobile
PET's Site Planning Guide.
"MOBILE PET"
MOBILE P.E.T. SYSTEMS, INC.,
A Delaware Corporation
By: _________________________ Date:_____________________
Its: _________________________
"CLIENT"
CLIENT NAME,
type and entity of state Date:_____________________
By: _________________________ ______________________________ (ADDRESS)
Its: _________________________ ______________________________ (CITY/STATE/ZIP)
SCHEDULES:
"A": The Equipment & Service Schedule.
"B": Support Services.
"C": Mobile PET Insurance.
"D": Patient Information/Authorization Sheet.
"E": Fees/Compensation.
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CLIENT NAME
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.
1. 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.)
1. 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 THAN 2 MIN/FRAME (47 SLICES)*
3D LESS THAN 7 MIN/FRAME (47 SLICES)**
4D LESS THAN 10 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.
1. 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.
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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/UCI/CC 780 KCPS/UCI/CC
UNIFORMITY LESS THAN 10% LESS THAN 10%
COUNTY RATE CORRECTION +/-5% UP TO 3.0UCI/Cc +/-5% UP TO 0.5UCi/CC
(111 KBQ/CC) (18.5 KBQ/CC)
1. 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.
1. 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.
1. 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"
STRATEGIC MARKETING PROGRAM:
- Seminar by expert PET Radiologist to educate Client's medical
staff on PET's benefits and indications.
- "Announcement of Service" letter to medical staff from radiology
and administration departments, reinforcing the availability of
PET service.
- Mass mailing of marketing materials to all area physicians.
- Provide "PET Patient Information Brochure."
LICENSING AND PROTOCOL ASSISTANCE FOR HANDLING RADIOPHARMACEUTICALS.
CONVENIENT AND TIMELY ACCESS TO RADIOPHARMACEUTICALS THROUGH MOBILE PET'S GROUP
PURCHASING AGREEMENT.
TRAINING OF CLIENT'S BUSINESS OFFICE PERSONNEL IN PET BILLING METHODOLOGY, CPT
CODES, REIMBURSEMENT DATA AND COLLECTION PROCEDURES.
PROFESSIONAL OVER-READ SERVICE FOR THE FIRST SIXTY (60) DAYS INCLUDED IN
TECHNICAL FEES ($100 PER CASE THEREAFTER BILLED DIRECTLY FROM PHYSICIAN
OVER-READ SERVICE PROVIDER).
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SCHEDULE "C"
(MPET INSURANCE)
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SCHEDULE "D"
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:
Section. ______________________________________ Date: ___________ What Body Region?___________________________
Section. ______________________________________ Date: ___________ What Body Region?___________________________
Have you had Radiation Therapy? ______Yes ______No
If Yes, please describe:
Section. ______________________________________ Date: ___________ What Body Region?___________________________
Section. ______________________________________ Date: ___________ What Body Region?___________________________
Have you had Chemotherapy? ______Yes ______No
If Yes, please describe:
Section. ______________________________________ Date: ___________ Drug: ___________________________________
Section. ______________________________________ Date: ___________ Drug: ___________________________________
Are you Diabetic: ______Yes ______No
If Yes, please describe Insulin therapy:
Section. Date: ___________ Drug: _______________________________
Section. Date: ___________ Drug: _______________________________
Have you had Vaccine Therapy: ______Yes ______No
If yes, please describe:
Section. Date: ___________ Injection Site: ____________________________
Section. Date: ___________ Injection Site: ____________________________
Date of last Vaccination: ____________________
Do you have:
Colostomies? ______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:
Section. ______________________________________ Date: ___________ What Body Region?_________________________
Section. ______________________________________ Date: ___________ What Body Region?_________________________
Are you Pregnant? ______Yes ______No
Have you consumed any liquids or food today? ______Yes ______No
If yes, please describe:
Section. ______________________________________ Time: ___________
Section. ______________________________________ 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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CLIENT NAME
SCHEDULE E
(CONFIDENTIAL)
SCHEDULED SERVICE DAYS: ONE DAY PER WEEK
FEES: FEE FOR SERVICE SCHEDULE
FIRST FOUR (4) PET EXAMS PER DAY OF SERVICE ------- $PRICE ONE PER EXAM
NEXT FOUR (4) PET EXAMS PER DAY OF SERVICE ------- $PRICE TWO PER EXAM
ADDITIONAL PET EXAMS PER DAY OF SERVICE -----------$PRICE THREE PER EXAM
A MINIMUM OF FOUR (4) EXAMS PER DAY OF SERVICE IS REQUIRED.
*PRICES DO NOT INCLUDE FDG
BY:__________________________________ DATE:_________________
FOR: CLIENT NAME
BY:__________________________________ DATE:_________________
FOR: MOBILE P.E.T SYSTEMS, INC.
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