We appreciate your interest in TA.
Please fill out this form for more information about our services. Someone will contact you shortly.
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Full Name :
Designation/Title :
Hospital/Practice :
Office Phone :
FAX :
Address 1 :
Address 2 :
City :
State
Zip :
Email :
Please tell us what services you are interested in:
	Evening/Night coverage
	Temporary/Locums Coverage
	Day Time weekend coverage area
	Weekend Night Coverage
	A complete Teleradiology Solution including the necessary equipment
Please tell us a little about your current call situation:
	We currently take call ourselves
	We employ radiologists just to take call
	We use another teleradiology service
Approximately how many stuides are done at your facility on an average night?
	1-5
	6-10
	11-20
	>20
	N/A
Please list approximate number of exams, exam types and whether you have DICOM output from your CT and MR scanners and US machines.