Dental Imaging Computer Replacement – Tech Intake Site & Work Order Practice Name Operatory / Room WO / Ticket # Technician Date Wall Unit / Imaging Hardware Wall Unit Mfr/Model Wall Unit Serial # Interface Type USB Ethernet Proprietary Interface Serial/ID Proprietary Notes (required if Proprietary checked) Imaging Network MAC IP DHCP/Static DHCPStatic Existing Imaging PC OS Windows 7Windows 10Windows 11Other CPU RAM Storage (up to 3 drives) HDD/SSD 1 Drive / Volume (e.g., C:) Drive Type HDDSSDNVMeOther Total Size (GB) Free Space (GB) HDD/SSD 2 Drive / Volume (e.g., D:) Drive Type HDDSSDNVMeOther Total Size (GB) Free Space (GB) HDD/SSD 3 Drive / Volume (e.g., E:) Drive Type HDDSSDNVMeOther Total Size (GB) Free Space (GB) NICs NIC 2 present NIC 3 present NIC 1 (Required) Type MAC IP DHCP/Static DHCPStatic NIC 2 Type MAC IP DHCP/Static DHCPStatic NIC 3 Type MAC IP DHCP/Static DHCPStatic HIPAA & ePHI Handling No patient data accessed Patient data accessed (view only) Patient data migrated / validated Image/data storage location verified Temporary files removed after work Notes / Exceptions Submit
