IT/Facility Repair Form

IT and Facility Repair Request Form

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

First NameLast 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.Format: (000) 000-0000.
Type of Request*
IT Request
Urgent-disrupting clinic operationsRegular-can wait 2-5 business days if needed
Workstation Number
Device if not computer issue
printer/hospital equipment/etc
Describe Issue
Facility Repair
Safety ConcernNeedWant
Describe Issue
Should be Empty:

IT and Facility Repair Request Form