17×48 long panel

Room Information Form

For a 2020 Imaging long-length chiropractic panel. Fill this in on a phone or a computer, then download a fillable blank PDF, download or print the completed PDF, or send the completed PDF to Fix My X-Ray.

Related: 17×48 Full-Spine DR Panel

Date

October 28, 2026, Mountain Time. The PDF writes this date, plus the dealer block, when you download it blank, download it filled, print it, or send it. The dealer block is not shown on this page.

Practice

2020 Imaging sales rep (optional)

Practice name *

Doctor name *

Doctor email *

Doctor phone *

Street address *

Address line 2

City *

State *

Postal code *

Equipment

Generator type *

Current SID *

Max SID the room is capable of *

X-ray tube type *

X-ray tube serial number *

Photographs

Drag a photo onto a box, or click to browse. One or two photos of the entire room, one of the tube, and one of the tube serial number. Do not include patients or screens that show patient names.

Room overview *Drag a photo here, or click to browse.JPG or PNG

Second room overviewDrag a photo here, or click to browse.JPG or PNG

X-ray tube *Drag a photo here, or click to browse.JPG or PNG

Tube serial number *Drag a photo here, or click to browse.JPG or PNG

Anti-spam check *

A numbers check, a hidden field, and a short time gate keep automated submissions out. Nothing is stored as an account.

Send delivers the filled PDF, including the photos, to the Fix My X-Ray inbox. It is not a plain-text copy of the fields. A clinic login is not created from this form.