Missouri Department of Health and Senior Services

Bureau of Diagnostic Services

Missouri Radiation Control Program
P.O. Box 570, 920 Wildwood, Jefferson City, MO 65102-0570
Phone: 573-751-6083 FAX: 573-751-6158
Email: MRCP@health.mo.gov

Registration of X-ray Service Companies

COMPANY NAME
STREET ADDRESS
CITY, STATE, ZIP CODE

Attention: Sales Manager or Customer Service Manager FACILITY CONTACT NAME

The Missouri Department of Health and Senior Services, Missouri Radiation Control Program has an informal registration
process for companies that offer sales/installation/service of x-ray equipment and related services. We have been informed of
your company, either from the FDA’s required reporting system for new x-ray equipment installation (Form 2579) or from
one of the facilities we regulate, and are sending you this form. Please complete and return it to our office as soon as possible.

We are asking that you register (or re-register) your company with our Department so that we may keep it on our referral list
of service companies. This is a list that we provide to facilities we regulate when they have service or equipment needs.
Through this process, we hope to benefit facilities as well as provide your company with referral business and new accounts.
If you have any questions, please contact our office at (573) 751-6083.

NOTE: We also request that you update this registration of your company every two (2) years.
Fax, e-mail, or mail this form to the following: FAX: (573) 751-6158 E-mail: MRCP@health.mo.gov

Missouri Radiation Control Program

Missouri Department of Health and Senior Services
PO Box 570, 920 Wildwood
Jefferson City MO 65102
FORMAL COMPANY NAME:

ADDRESS:

CITY, STATE ZIP

PHONE/FAX:

CONTACT PERSON(S):
E-MAIL ADDRESS:

PRIMARY SERVICE AREA:

Statewide St Louis/East MO KC/West MO SE MO SW MO Other-specify areas:

Regional Offices--City Phone Number Contact Person Comment

CONTINUED ON NEXT PAGE

www.health.mo.gov

Healthy Missourians for life.

The Missouri Department of Health and Senior Services will be the leader in promoting, protecting and partnering for health.

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER: Services provided on a nondiscriminatory basis.

Radiation Producing Sales Sales Installation Installation Service/ Disassembly/ Related
Electronic Equipment (New) (Used) (New) (Used) Repair/ Disposal Supplies
Calibration
Dental
Medical Radiographic
Chiropractic Radiographic
Veterinary Radiographic
Podiatric Radiographic
Mammography
Fluoroscopic
C.T.
Bone Densitometry
Radiation Therapy (Lineac)
Nuclear Medicine Sales Sales Installation Installation Service/ Disassembly/ Related
(New) (Used) (New) (Used) Repair/ Disposal Supplies
Calibration
Rad Materials (Diagnostic)
Calibration Sources
Detectors, Gamma
Cameras
Non-Ionizing Radiation Sales Sales Installation Installation Service/ Disassembly/ Related
Producing Equipment (New) (Used) (New) (Used) Repair/ Disposal Supplies
Calibration
Ultrasound Machines
MRI
Medical Surgical Lasers
Image Processing Sales Sales Installation Installation Service/ Disassembly/ Related
(New) (Used) (New) (Used) Repair/ Disposal Supplies
Calibration
Film (Wet) Processors
Laser Processors
Digital (PACS, etc)
Film Sales
Dosimetry/Instruments Sales Sales Installation Installation Service/ Disassembly/ Related
(New) (Used) (New) (Used) Calibration Disposal Supplies
Personnel Monitoring
(badges)
Detecting Equipment
(GM’s)
QC/QA Equipment
Non-Medical/Industrial Sales Sales Installation Installation Service/ Disassembly/ Related
X-ray (New) (Used) (New) (Used) Calibration Disposal Supplies
Cabinet x-ray
XRF
Other (Describe below)
:
Consultation N/A N/A N/A N/A N/A N/A
Room Design/Shielding
QC/QA Troubleshooting
Training of Personnel
(Specify Type below)