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Exhibit 4.9    
    

SIXTH SUPPLEMENTAL INDENTURE

        This
Sixth Supplemental Indenture, dated as of May 10, 2004 (this "Supplemental Indenture" or
"Guarantee"), among Cape Fear Mobile Imaging, LLC, a North Carolina limited liability company (the
"Guarantor"), MedQuest, Inc. (together with its successors and assigns, the "Company"), MQ
Associates, Inc. ("Holdings"), the subsidiaries of the Company party to the Indenture (as hereinafter defined) (the
"Subsidiary Guarantors") and Wachovia Bank, National Association, as Trustee under the Indenture referred to below. 

WITNESSETH:

        WHEREAS, the Company, Holdings, the Subsidiary Guarantors and the Trustee have heretofore executed and delivered an Indenture, dated as of
August 15, 2002 (as amended, supplemented, waived or otherwise modified, the "Indenture"), providing for the issuance of an aggregate principal
amount of $180,000,000 of 117/8% Senior Subordinated Notes due 2012 of the Company (the "Securities") 

        WHEREAS, Section 3.12 of the Indenture provides that unless such Subsidiary has
previously issued a Notes Guarantee which is then in full force and effect, the Company is required to cause each Subsidiary that issues a Guarantee in respect of obligations under a Credit Facility
to execute and deliver to the Trustee a supplemental indenture pursuant to which such Restricted Subsidiary will unconditionally Guarantee, on a joint and several basis with the other Guarantors, the
full and prompt payment of, premium, if any, and interest on the Securities; and 

        WHEREAS, pursuant to Section 9.1 of the Indenture, the Trustee and the Company are
authorized to execute and deliver this Supplemental Indenture to amend the Indenture, without the consent of any Securityholder; 

        NOW, THEREFORE, in consideration of the foregoing and for other good and valuable consideration, the receipt of which is hereby
acknowledged, the Guarantor, the Company, Holdings, the other Subsidiary Guarantors and the Trustee mutually covenant and agree for the equal and ratable benefit of the Holders of the Securities as
follows: 

 
 

ARTICLE I
  
  DEFINITIONS    
    

1.1    Defined Terms.  

        As used in this Supplemental Indenture, terms defined in the Indenture or in the preamble or recital hereto are used herein as therein defined, except that the
term "Holders" in this Guarantee shall refer to the term "Securityholders" as defined in the Indenture
and the Trustee acting on behalf or for the benefit of such Holders. The words "herein," "hereof" and "hereby" and other words of similar import used in this Supplemental Indenture refer to this
Supplemental Indenture as a whole and not to any particular section hereof. 

 

 
 

ARTICLE II
  
  AGREEMENT TO BE BOUND; GUARANTEE    
    

2.1    Agreement to be Bound.  

        The Guarantor hereby becomes a party to the Indenture as a Subsidiary Guarantor and as such will have all of the rights and be subject to all of the obligations
and agreements of a Subsidiary Guarantor under the Indenture. The Guarantor agrees to be bound by all of the provisions of the Indenture applicable to a Subsidiary Guarantor and to perform all of the
obligations and agreements of a Subsidiary Guarantor under the Indenture. 

2.2    Guarantee.  

        The Guarantor as of the Guarantor Effective Date (as hereinafter defined) hereby fully, unconditionally and irrevocably guarantees, as primary obligor and not
merely as surety, jointly and severally with each other Subsidiary Guarantor, to each Holder of the Securities and the Trustee, the full and punctual payment when due, whether at maturity, by
acceleration, by redemption, or otherwise, of the Obligations pursuant to Article XI of the Indenture. 

 
 

ARTICLE III
  
  MISCELLANEOUS    
    

3.1    Notices.  

        All notices and other communications to the Guarantor shall be given as provided in the Indenture to the Guarantor, at its address set forth below, with a copy to
the Company as provided in the Indenture for notices to the Company. 

3.2    Parties.  

        Nothing expressed or mentioned herein is intended or shall be construed to give any Person, firm or corporation, other than the Holders and the Trustee, any legal
or equitable right, remedy or claim under or in respect of this Supplemental Indenture or the Indenture or any provision herein or therein contained. 

3.3    Governing Law.  

        This Supplemental Indenture shall be governed by, and construed in accordance with, the laws of the State of New York. 

3.4    Severability Clause.  

        In case any provision in this Supplemental Indenture shall be invalid, illegal or unenforceable, the validity, legality and enforceability of the remaining
provisions shall not in any way be affected or impaired thereby and such provision shall be ineffective only to the extent of such invalidity, illegality or unenforceability. 

2

 

3.5    Ratification of Indenture; Supplemental Indentures Part of Indenture.  

        Except as expressly amended hereby, the Indenture is in all respects ratified and confirmed and all the terms, conditions and provisions thereof shall remain in
full force and effect. This Supplemental Indenture shall form a part of the Indenture for all purposes, and every Holder of Securities heretofore or hereafter authenticated and delivered shall
be bound hereby. The Trustee makes no representation or warranty as to the validity or sufficiency of this Supplemental Indenture. 

3.6    Counterparts.  

        The parties hereto may sign one or more copies of this Supplemental Indenture in counterparts, all of which together shall constitute one and the same agreement. 

3.7    Headings.  

        The headings of the Articles and the sections in this Supplemental Indenture are for convenience of reference only and shall not be deemed to alter or affect the
meaning or interpretation of any provisions hereof. 

3.8    Additional Definitions.  

        As used in this Supplemental Indenture, "Guarantor Effective Date" shall mean April 30, 2004. 

[signature
page follows] 

3

 

        IN WITNESS WHEREOF, the parties hereto have caused this Supplemental Indenture to be duly executed as of the date first above written. 

	

 	
 	

CAPE FEAR MOBILE IMAGING, LLC,

as a Guarantor
	

 	
 	

By:	
 	

/s/  JOHN K. LUKE      
 Name: John K. Luke

Title:    Manager
	

 	
 	

WACHOVIA BANK NATIONAL

ASSOCIATION, as Trustee
	

 	
 	

By:	
 	

/s/  PAUL HENDERSON      
 Name: Paul Henderson

Title:    Trust Officer
	

 	
 	

MEDQUEST, INC.
	

 	
 	

By:	
 	

/s/  JOHN K. LUKE      
 Name: John K. Luke

Title:    President
	

 	
 	

MQ ASSOCIATES, INC.
	

 	
 	

By:	
 	

/s/  JOHN K. LUKE      
 Name: John K. Luke

Title:    President

4

 

	IMAGING SERVICES OF ALABAMA, INC.

ANDERSON DIAGNOSTIC IMAGING, INC.

ASHEVILLE OPEN MRI, INC.

BIOIMAGING AT CHARLOTTE, INC.

BIOIMAGING AT HARDING, INC.

BIOIMAGING OF COOL SPRINGS, INC.

CABARRUS DIAGNOSTIC IMAGING, INC.

CAPE FEAR DIAGNOSTIC IMAGING, INC.

CAROLINA IMAGING, INC. OF FAYETTEVILLE

CHAPEL HILL DIAGNOSTIC IMAGING, INC.

CHATTANOOGA DIAGNOSTIC IMAGING, INC.

DOTHAN DIAGNOSTIC IMAGING, INC.

FLORIDA DIAGNOSTIC IMAGING CENTER, INC.

OPEN MRI OF GEORGIA, INC.

OPEN MRI & IMAGING OF GEORGIA, INC.

GROVE DIAGNOSTIC IMAGING CENTER, INC.

KANSAS DIAGNOSTIC IMAGING, INC.

NORTHEAST COLUMBIA DIAGNOSTIC IMAGING, INC.

WISCONSIN DIAGNOSTIC IMAGING, INC.

VIENNA DIAGNOSTIC IMAGING, INC.

WILLIAM S. WITT, INC.	 	MRI & IMAGING OF WISCONSIN, INC.

LEXINGTON OPEN MRI, INC.

MECKLENBURG DIAGNOSTIC IMAGING, INC.

MEDQUEST ASSOCIATES, INC.

MISSOURI IMAGING, INC.

MOBILE OPEN MRI, INC.

OCCUPATIONAL SOLUTIONS, INC.

PALMETTO IMAGING, INC.

PHOENIX DIAGNOSTIC IMAGING, INC.

PIEDMONT IMAGING, INC. (FORSYTH)

PIEDMONT IMAGING, INC. (SPARTANBURG)

OPEN MRI & IMAGING OF RICHMOND, INC.

SOUTH CAROLINA DIAGNOSTIC IMAGING, INC.

SUN VIEW HOLDINGS, INC.

TEXAS IMAGING SERVICES OF EL PASO, INC.

TRIAD IMAGING, INC.

TYSON'S CORNER DIAGNOSTIC IMAGING, INC.

VIRGINIA DIAGNOSTIC IMAGING, INC.

CAROLINAS DIAGNOSTIC IMAGING, INC.

ILLINOIS DIAGNOSTIC IMAGING, INC.
	On behalf of each of the entities listed above:	 	On behalf of each of the entities listed above:

	

By:	
 	

/s/  JOHN K. LUKE      
 Name: John K. Luke

Title: President	
 	

By:	
 	

/s/  JOHN K. LUKE      
 Name: John K. Luke

Title:    President

5

 

	OPEN MRI & IMAGING OF ALBANY, LLC

OPEN MRI & IMAGING OF ATHENS, LLC

ATHENS MRI, LLC

OPEN MRI OF ATLANTA, LLC

BUCKHEAD DIAGNOSTIC IMAGING, LLC

OPEN MRI OF CENTRAL GEORGIA, LLC

IMAGING CENTER OF CENTRAL GEORGIA, LLC

OPEN MRI & IMAGING OF CONYERS, LLC

CUMMING DIAGNOSTIC IMAGING, LLC

OPEN MRI & IMAGING OF DEKALB, LLC

DULUTH DIAGNOSTIC IMAGING, LLC

DULUTH CT CENTER, LLC

DIAGNOSTIC IMAGING OF ATLANTA, LLC

OPEN MRI & IMAGING OF NORTH FULTON, LLC

OPEN MRI & IMAGING OF N.E. GEORGIA, LLC

DIAGNOSTIC IMAGING OF GEORGIA, LLC

MIDTOWN DIAGNOSTIC IMAGING, LLC

OPEN MRI & IMAGING OF DOUGLASVILLE, LLC

HAPEVILLE DIAGNOSTIC IMAGING, LLC

OPEN MRI & IMAGING OF MACON, LLC

OPEN MRI AND IMAGING OF SNELLVILLE, LLC

WEST PACES DIAGNOSTIC IMAGING, LLC

TOWN & COUNTRY OPEN MRI, LLC

BRUNSWICK DIAGNOSTIC IMAGING, LLC	 	WOODSTOCK DIAGNOSTIC IMAGING, LLC

DIAGNOSTIC IMAGING OF HIRAM, LLC

DIAGNOSTIC IMAGING OF MARIETTA, LLC

MONTGOMERY OPEN MRI, LLC

BIRMINGHAM DIAGNOSTIC IMAGING, LLC

COASTAL IMAGING, LLC

DURHAM DIAGNOSTIC IMAGING, LLC

JACKSONVILLE DIAGNOSTIC IMAGING, LLC

CAPE IMAGING, L.L.C.

BRIDGETON MRI AND IMAGING CENTER, LLC

KIRKWOOD MRI AND IMAGING CENTER, LLC

ST. PETERS MRI & IMAGING CENTER, LLC

OPEN MRI & IMAGING OF RICHMOND, LLC

RICHMOND WEST END DIAGNOSTIC IMAGING, LLC

CAROLINA MEDICAL IMAGING, LLC

OPEN MRI OF SIMPSONVILLE, LLC

SIMPSONVILLE OPEN MRI, LLC

EAST COOPER DIAGNOSTIC IMAGING, LLC

FARMFIELD DIAGNOSTIC IMAGING, LLC

FORT MILL DIAGNOSTIC IMAGING, LLC

TRICOM DIAGNOSTIC IMAGING, LLC

WEST ASHLEY DIAGNOSTIC IMAGING, LLC

CLAYTON OPEN MRI, LLC

MEDICAL SCHEDULING OF MISSOURI, LLC
	

On behalf of each of the entities listed above:	
 	

On behalf of each of the entities listed above:

	

By:	
 	

/s/  JOHN K. LUKE      
 Name: John K. Luke

Title:    Manager	
 	

By:	
 	

/s/  JOHN K. LUKE      
 Name: John K. Luke

Title:    Manager
	

 	
 	

 	
 	

OPEN MRI & IMAGING OF FLORENCE, LLC

OPEN MRI OF MYRTLE BEACH, LLC

Palmetto Imaging, Inc., as sole member of each of the entities listed above
	

 	
 	

 	
 	

By:	
 	

/s/  JOHN K. LUKE      
 Name: John K. Luke

Title:    President

6

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Exhibit 4.9

ARTICLE I DEFINITIONS

ARTICLE II AGREEMENT TO BE BOUND; GUARANTEE

ARTICLE III MISCELLANEOUSQuickLinks
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Exhibit 10.20    
    

April 27,
2004 

PRIVATE AND CONFIDENTIAL  

DLJ
Merchant Banking II, Inc.

11 Madison Avenue

New York, NY 10010 

Von
Hoffmann Corporation

1000 Camera Avenue

St. Louis, MO 63126 

Ladies
and Gentlemen: 

Reference
is hereby made to that certain letter agreement dated March 26, 2002, as amended (the "Amendment") on October 31, 2003 (as
amended, the "Agreement"), a copy of which is attached hereto, between Credit Suisse First Boston Corporation (n/k/a Credit Suisse First Boston LLC
"CSFB") and Von Hoffmann Corporation (the "Company"). Capitalized terms used and not otherwise defined
herein shall have the meanings assigned to such terms in the Agreement. 

CSFB
hereby assigns as of the date hereof all of its rights and obligations under the Agreement to DLJ Merchant Banking II, Inc. ("Merchant
Banking"), and Merchant Banking hereby assumes as of the date hereof all of the rights and obligations of CSFB under the Agreement. The Company hereby consents to such
assignment and assumption, and the Company shall pay to Merchant Banking, instead of the amounts and the times set forth in paragraph 2(a) of the Agreement, the Annual Fee in the amount, and at
the times, set forth in the following paragraph. 

Merchant
Banking and the Company hereby agree that after giving effect to the foregoing assignment (i) the waiver of the Annual Fee referenced in the Amendment is hereby terminated;
(ii) the Agreement shall be valid and effective for a term of one (1) year from the date hereof; (iii) the Annual Fee due and payable for 2004 (i.e. $500,000) shall be paid by the
Company within three (3) business days following the date hereof; and (iv) paragraph 5 (Additional Services) of the Agreement is deleted in its entirety. 

Notwithstanding
the foregoing, CSFB and its affiliates shall have the rights and benefits provided by the indemnity set forth on Annex A to the Agreement (in addition to, and not to the exclusion of,
Merchant Banking) for any advisory services rendered or failed to be rendered by CSFB to the Company pursuant to the Agreement prior to the date hereof. 

Please
confirm your agreement with the foregoing by signing in the space indicated below and returning an executed copy of this letter to CSFB. 

	 	 	Very truly yours,	 	 
	

 	
 	

CREDIT SUISSE FIRST BOSTON LLC	
 	

 
	

 	
 	

By:	

/s/  EDWARD YORKE      
 Name: Edward Yorke

Title: Authorized Signatory	
 	

 
	 	 	 	 	 	 

Accepted and agreed to

this 27th day of April, 2004 

DLJ
MERCHANT BANKING II, INC. 

	By:	/s/  MICHAEL ISIKOW      
 Name: Michael Isikow

Title: Vice President	 	 	 	 
	 	 	 	 	 	 

Acknowledged and agreed to

this 27th day of April, 2004 

VON
HOFFMANN CORPORATION 

	By:	/s/  GARY WETZEL      
 Name: Gary Wetzel

Title: Chief Financial Officer	 	 	 	 
	 	 	 	 	 	 

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Exhibit 10.20

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