Equipment Swap Requests Form
http://tinyurl.com/vxswap
Your Email Address
*
you@luneautech.com
Manager to Approve
*
Please Select
l.brown@visionix.com
matt.vulich@visionix.com
K.Walsh@visionix.com
Email address of Manager to Approve
*
example@example.com
Account Name
*
Account Phone Number
Please enter a valid phone number.
Account Address
*
Contact Name
*
First Name
Last Name
Contact Email
*
example@example.com
Confirm Contact Email Address
*
example@example.com
EMAIL ADDRESS DOES NOT MATCH!!!!
Case#
*
SAP Acct#
*
Equipment Name and Part#
*
Please Select
Other
AirMax - NA-02260
Briot Attitude GTS Lab Tracer - BTAWW
Briot Attitude I Lens Edger - BMDHBAAW
Briot Attitude II Lens Edger - BNDHBBAW
Briot Attitude Tracer / Blocker - BLABBWW
Briot Couture Lens Edger - BSDHBBWW
Briot Couture Tracer / Blocker - BUABBWW
Briot Emotion 2 Lens Edger - BFAAWZAW
Briot EVO XS2 Scan 8 + Evolution Tracer / Blocker - S280017
Briot Evolution GT Remote Tracer - BQABWW
Briot Evolution HC Lens Edger - BOAHBAAW
Briot Evolution Tracer / Blocker - BPABWW
Briot Perception 2 Groove Lens Edger - BGAAWZAW
Briot Perception 2 Lens Edger - BGAAWZBW
Briot Scan 8 HC Tracer Briot Adapter - BRABWW
Briot Scan 8 HC Tracer Weco Adapter - BRAWWW
Briot Tracer Attitude/E6 GTS - BTAWW
Nexy Fundus Camera - 8510-0008-00
Optovue Assy Scanner iVue NR - 700-49494-001
Optovue Assy Scanner iVue NR with New CAM and Spectrometer - 700-49973-002
Optovue Assy Scanner iVue80 - 700-54520-001
Optovue Assy Scanner Top iVue80 - 500-54521-001
Optovue Assy, Complete, Scanner, SOLIX v2 - 700-50245-002
Optovue Assy, Scanner Head, SOLIX - 500-50243-001
Optovue Assy, Scanner, Complete, SOLIX v1 - 700-50245-001
Optovue Cover, Scanner, Left, Solix - 530-53321-001
Optovue Cover, Scanner, Right, Solix - 530-53322-001
Optovue iCam 12MP - 700-54524-001
Optovue iCam 5mp - 700-49517-004
Optovue iFusion 80 with 12MP Fundus Camera - 700-54542-001
Optovue iScan 80 - 700-54544-001
Optovue iVue 80 - 700-54543-001
Optovue OCT iScan 1 - 700-49428-002
Optovue OCT iScan system - 700-52801-002
Optovue OCT iVue80 System - 700-54543-001
Optovue OCT XR Avanti System - 700-54852-001
Optovue Packaging, Scanner, eVue Solix - 505-50582-001
Optovue RTVue XR Avanti - 700-54852-001
Optovue RTVue XR Avanti (AngioVue Comprehensive) - 700-54345-001
Optovue Solix Essential - 700-55007-001
Optovue Solix - 700-51423-002
PARANI-SD1000 BLUETOOTH - NA-PARANI-SD1000-0
Visionix Eye Refract (VX 160) - 30230000-10
Visionix VX 110+ - 30200000-21
Visionix VX 118+ - NA-3020-0000-10
Visionix VX 120+ - 30200000-12
Visionix VX 120+ Dry Eye - 30200000-05
Visionix VX 130+ - 30200000-03
Visionix VX 22 - 8240-0022-01
Visionix VX 25 - 8225-0000-01
Visionix VX 36 - 8236-0001-00
Visionix VX 40 - 30140000-10
Visionix VX 40 adjustable table - 8160-8025-00
Visionix VX 65(Control Panel) - 8265-8001-00
Visionix VX 65(Head only + Software) - 8265-0000-01
Visionix VX 65(with Tablet, no Chart) - 8265-0000-00
Visionix VX 650 - 30260000-10
Visionix VX 90 - 8290-0001-00
Visionix VXBOX 2 - 8216-1001-03
Weco C4 Tracer / Blocker - WPAWWW
Weco C6 Tracer / Blocker - WLAWXWW
Weco C6i Industrial Line - WLAWXAI
Weco E12 Groove Lens Edger - WOAAWZBW
Weco E12 Lens Edger - WOAAWZAW
Weco E32 Lens Edger - WNAAWZAW
Weco E5 Lens Edger - WIAHWAAW
Weco E5s line Lens Edger - WIAAWAAW
Weco E6 Lens Edger - WKLHWFWAW
Weco E6s line Lens Edger - WJLHWWWAW
Weco T6 HC Tracer - WRAWWW
Is Topo Installed?
*
Yes
No
Other Name and Part#
Serial Number
*
Software Version
*
Warranty Status
*
Under Warranty
Out of Warranty
Equipment Age
*
Equipment Age
*
Years
Months
Reason for Swap
Can the unit be repaired in the field?
*
Yes
No
Shipping Method
*
Please Select
UPS Ground
UPS Overnight (needs prior manager approval)
UPS 2nd Day (needs prior manager approval)
Freight service required
None
Delivery Request
*
Please Select
ASAP
NO RUSH
Specified Delivery Date
Specified Delivery Date
/
Month
/
Day
Year
Date
Return Address is same as Ship to
*
Yes
No
Return Address
Return RMA Needed
*
YES
NO
Customer Kit Required? Each kit costs an avg of $125
Yes
No
Who is Handling the actual equipment swap?
*
Field Service Engineer
CAS
The Customer
FSE Email Address for notification
*
example@example.com
Handling the Swap?
*
First Name
Last Name
Attachments
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Sales Persons email address
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