X-RAY CT SCANNER

PRODUCTS
TUBE SERVICE REPORT
Attention: Customer Service Dept. Tubes must be returned prepaid with a completed Tube Service
Report describing the reason for return, operating conditions,
RA Number: installed and removal dates in order to receive warranty consider-
ation. As the Customer is responsible for the return of the product
Varian SLC Fax Number: 801-973-5050 to Varian, the original packing or reasonable facsimile should be
used to avoid damage during transport.
Customer Fax Number: NOTE: All housings must be cleaned of blood, contrast media and
Customer E-mail any body fluid residue, before returning.
To obtain a return authorization number please e-mail,
www.varian.com/us/xray/services_support.html scan or fax a completed copy of this form to Varian.

Dealer/OEM
Name
Address
City State Zip Country

Return Tube Information

Insert Model Serial Number
Heat Exchanger Model Serial Number
Scanner Model Serial Number

Institution (Where Tube Installed)

Name
Address
City State Zip Country

X-Ray Tube Operation or Heat Exchanger if returned separately Anode Rotation Speed
Date Removed Scan Count Estimated Scans @ 60 Hz
Date Installed Scan Count Estimated Scans @ 180 Hz
Total Scans
Heat Exchanger Total Hours (if applicable)

Techniques at Time of Difficulty kV mA Time

Techniques Most Frequently Used kV mA Time

Describe in detail the circumstances and reasons for the removal and return: (If the cause of failure
was arcing: Describe the arcing pattern and also record the frequency of arcing)

Replacement Tube or Heat Exchanger

Insert or HE Model S/N

Additional Comments

Person Filing Report

Please Print Name Telephone Date

4908 Rev C 05/09 1678 South Pioneer Road / Salt Lake City, Utah 84104 / (801) 972-5000