Equipment Repair/PM Request Form

Equipment Repair/PM Request Form
Request Date

MonthDayYear
Date
Customer Information
Name

First NameLast Name
Practice or Facility Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Briefly describe how we can help you
Equipment Information

List of Equipment

	Model/Part No.	Item Description	Quantity	Problem Description
1
2
3
4
5
6
7
8
9

Do you have any special instructions?
Notes and Reminders
Once we receive this form submission, we'll call you over the phone to make sure that we have the correct information.

Depending on your location, we can send someone to either repair the item(s) on site or pick up the equipment for troubleshooting in our repair center. You can also send it to our repair center using the waybill that we'll provide.

If we bring the broken equipment into our repair center, we will begin troubleshooting within 3 days and then provide you with a quotation for repair. Depending on the availability of parts, we should finish the repair within 5-7 business days.

We will be in constant contact with you throughout the process. Once repaired, we will return the unit to you and provide a 120 day warranty on the labor. The replacement part(s) is warranteed by the manufacturer.
Please verify that you are human*
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