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    Practice Name*





    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