New Service Request

Request a quote * = required field Cancel

Please fill out the form below to have a West Physics representative contact you to arrange for a service or product quote for your facility.

Full name*
Title*
Email*
Phone
Company or Facility Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Brief Description of Service or Product Needs*
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Our address and telephone numbers are:

West Physics
3825 Paces Walk SE
Suite 250
Atlanta, GA 30339

770-435-9186 • 1-866-275-9378 • FAX 770-599-2333

Office Hours: West Physics maintains liberal office hours for the convenience of our customers nationwide.

Monday-Friday:

9AM – 8PM Eastern Time
8AM – 7PM Central Time
7AM – 6PM Mountain Time
6AM – 5PM Pacific Time

Closed Weekends & U.S. National Holidays

This form is intended for existing West Physics customers requesting to add new services in addition to services currently provided. If your facility is not currently receiving services from West Physics, proceed to the home page and request a quote for services you desire.

To ensure your scheduling, billing, and reporting processes go as smoothly as possible, please provide the following information.
Contact [email protected] for any questions.

Facility Name:*
Address Where Services Will Occur:*
Additional Site Info:*

Special instructions for West Physics staff (e.g. parking, security, building or suite location when they arrive on-site)
Modality:*
Additional Info:*

(Provide additional information if “Other” was selected from the Modality dropdown)
Location / Equipment Information
Floor:
Department:*
Room Name:*
Room Number:*
Additional Info: (Descriptive info to assist location the unit)*
Manufacturer Name: (e.g. GE, Siemens, Xoran)*
Model: (e.g. 9800 Plus, Espree)*
For MRI Units, Provide Magnet Strength:*
Last Survey Date:*
- Select Date
- Unknown
Date*

MM slash DD slash YYYY
Is a Radiation Shield Design Needed?:*
- Yes
- No
Is a Radiation Protection Survey Needed?:*
- Yes
- No
Scheduling Information
Service Date Request:*

MM slash DD slash YYYY

(Provide date you would prefer to have the NEXT survey completed)
Testing Required:*

(Choose the type of testing this unit needs at the time of its next survey (i.e., ACR, State, Joint Commission, etc.) All radiation-emitting equipment is assumed to require at minimum state-compliant physics testing. All Joint Commission facilities are assumed to require at minimum Joint Commission-compliant physics testing for advanced modalities (CT, MRI, NucMed, Mammo). If you are a Joint Commission facility, please choose ‘ACR’ or ‘IAC’ for any units accredited by those bodies, and ‘TJC’ for any others.)
Scheduling Contact Information
Name*

Title:*

Phone number:*

Email:*
Report Contact Information
Name*

Title*

Phone number:*

Email:*
Billing Information For Invoices
Name:*
Title:*
Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Phone number:*
Email:*
PO# and Terms

(If your facility or network will be issuing a PO for the listed service)
PO #:
Terms: (e.g. 1 year of service, 3 years of service)
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*Indicates a Required Field

Request a quote * = required field Cancel

Monday-Friday:

Location / Equipment Information

Scheduling Information

Scheduling Contact Information

Report Contact Information

Billing Information For Invoices

PO# and Terms