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Practice Name*

Address

Name*

Title

Email*

Referring Representative

How many nuclear cardiac studies are you performing each month?*

Who is your current radiopharmaceutical supplier?

Does your lab use:

What is your current radiopharmaceutical per dose cost?

When is your current contract over?

Does your current contract have an early termination option?

Does your lab use:

Cost per dose

In addition to radiopharmaceuticals, which other LHS services are you interested in?

Number of SPECT system(s)

Type of SPECT system(s)

*Required field