IT/Facility Repair Form

IT and Facility Repair Request Form

Please fill out completely and submit.
Clinic Name
Name of person requesting

First Name Last Name
Is a follow up communication wanted? If yes please provide the best way to contact you, either email or phone number.
Email
example@example.com
Phone Number
Please enter a valid phone number.
Type of Request *
IT Request
Priority

Urgent-disrupting clinic operations Regular-can wait 2-5 business days if needed
Workstation Number
Device if not computer issue
printer/hospital equipment/etc
Describe Issue
Facility Repair
Priority

Safety Concern Need Want
Describe Issue
Should be Empty:

IT and Facility Repair Request Form