CONNECTIVITY REQUEST FORM ULTRASOUND

TOSHIBA MEDICAL SYSTEMS

Page 1

General data

HOSPITAL
Hospital name:
address:
city:
country:
Department:
Room Number:
Contact Person: Phone : Fax : E-Mail:
Network Admin.: Phone : Fax : E-Mail:
other:

Modality US
Vendor: TOSHIBA MEDICAL SYSTEMS remarks:
type: XARIO SSA-660A
IP address: as given by network admin
subnet mask: as given by network admin
default gateway: as given by network admin
System name followed by
host name: T660xxxx
last 4 digits of serialn.
logical name: aplio aplio
port nr: 2000 2000
AE title: aplio aplio

Quantity of DICOM devices

PACS: remarks:
MWM:
MPPS:
Print:
SR:
other:
 CONNECTIVITY REQUEST FORM ULTRASOUND
TOSHIBA MEDICAL SYSTEMS
Page 2

PACS data

1. PACS (storage SCP)

available: yes no remarks:
Vendor: TOSHIBA info for
type: hospital and vendor
IP address: as given by network admin
host name:
logical name:
port nr: 2000
AE title: aplio
Implicit little Endian
transfer syntax:
Explicit little Endian
Structure Report yes no Type Basic

PACS (storage commitment SCU)

available: yes no remarks:
Vendor: TOSHIBA info for
type: hospital and vendor
IP address: as given by network admin
host name
logical name:
port nr: 2000
AE title: aplio

PACS (Query / Retrieve SCU - SCP)

available: yes no remarks:
Vendor: TOSHIBA info for
type: hospital and vendor
IP address: as given by network admin
host name
logical name:
port nr: 2000
AE title: aplio

2. PACS (storage SCP)

available: yes no remarks:
Vendor: TOSHIBA info for
type: hopital and Vendor
IP address: as given by network admin
host name:
logical name:
port nr: 2000
AE title: aplio
Implicit little Endian
transfer syntax:
Explicit little Endian
Structure Report yes no Type Basic

3. PACS (storage SCP)

available: yes no remarks:
Vendor: TOSHIBA info for
type: hopital and Vendor
IP address: as given by network admin
host name:
logical name:
port nr: 2000
AE title: aplio
Implicit little Endian
transfer syntax:
transfer syntax:
Explicit little Endian
Structure Report yes no Type Basic
 CONNECTIVITY REQUEST FORM ULTRASOUND
TOSHIBA MEDICAL SYSTEMS
Page 3

MWM MPPS data

Modality Worklist Management SCP

available: yes no remarks:
Vendor: TOSHIBA info for
type: hospital and vendor
IP address: as given by network admin
host name: as given by network admin
logical name: as given by network admin
port nr: 2000
AE title: aplio

Modality Performed Procedure Step SCP

available: yes no remarks:
Vendor: TOSHIBA info for
type: hospital and vendor
IP address: as given by network admin
host name: as given by network admin
logical name: as given by network admin
port nr: 2000
AE title: aplio
 CONNECTIVITY REQUEST FORM ULTRASOUND
TOSHIBA MEDICAL SYSTEMS
Page 4

Printer data

1. gray scale PRINT SCP

available: yes no remarks:
Vendor: TOSHIBA info for
type: hospital and vendor
IP address: as given by network admin
host name: as given by network admin
logical name: as given by network admin
port nr: 2000
AE title: aplio
film type:
film size:
other:

2. gray scale PRINT SCP

available: yes no remarks:
Vendor: TOSHIBA info for
type: hospital and vendor
IP address: as given by network admin
host name: as given by network admin
logical name: as given by network admin
port nr: 2000
AE title: aplio
film type:
film size:
other:

3. gray scale PRINT SCP

available: yes no remarks:
Vendor: TOSHIBA info for
type: hospital and vendor
IP address: as given by network admin
host name: as given by network admin
logical name: as given by network admin
port nr: 2000
AE title: aplio
film type:
film size:
other: