Annual Equipment Service Request

Annual Equipment Service Request

Annual Equipment Service Request

Please review the services listed below and select the ones you'd like included during your upcoming service visit.
Name of person requesting service*

First NameLast Name
Clinic Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Are you a VetStrategy Practice?*

YesNo
Please enter the ServiceChannel tracking/ticket number associated with this service call:
If you do not have a tracking/ticket number, please contact Facilities after filling out this form. You must have approval from Facilities to schedule a service call.
Please select the equipment you would like serviced from the list below.

Be sure to include the manufacturer, model, and serial number for each item. Missing information may result in additional service call fees or a delay in scheduling.
Anesthesia Machine(s) - Recommended yearly*

Yes, includeNo, decline
Please include the manufacturer, model, and serial number for each piece of equipment. Without this information, our biomedical team may not be able to complete the service.*
Do you have one of the following autoclaves?

Tuttnauer 2340/2540Tuttnauer 3870Tuttnauer 5075Midmark/Ritter M9 or M11
How many Anesthesia Machines require servicing?
Vaporizer Calibration(s) - Recommended every 2-3 years, depending on use*

Yes, includeNo, decline
Please include the manufacturer, model, and serial number for each piece of equipment. Without this information, our biomedical team may not be able to complete the service.*
How many Vaporizers require servicing?
Autoclave(s) - Recommended yearly*

Yes, includeNo, decline
How many Autoclaves require servicing?
Please include the manufacturer, model, and serial number for each piece of equipment. Without this information, our biomedical team may not be able to complete the service.*
Dental Machine(s) - Recommended yearly*

Yes, includeNo, decline
Please include the manufacturer, model, and serial number for each piece of equipment. Without this information, our biomedical team may not be able to complete the service.*
How many Dental Machines require servicing?
Microscope(s) - Recommended yearly*

Yes, includeNo, decline
Please include the manufacturer, model, and serial number for each piece of equipment. Without this information, our biomedical team may not be able to complete the service.*
Do you have other equipment, not listed, that you would us to service?*

YesNo
Please include the manufacturer, model, and serial number for each piece of equipment. Without this information, our biomedical team may not be able to complete the service.*
How many Microscopes require servicing?
Scavenge System Assessment - Recommended yearly (CVO requires every 24 months)*

Yes, includeNo, decline
Please let us know if there are certain days of the week when your equipment will be out of use and available for service.*
Example: We do not have surgery on Mondays and Fridays, we typically finish surgery by noon all other days.
If you haven't received one already, would you like us to provide a quote for service?*

YesNo
Please include any notes for our team here:
Feel free to add any pictures or videos of equipment if needed.

Cancelof
Please note that depending on the complexity of any issues we may discover during the service call, more than one service visit may be required to fully resolve the situation. While we strive to complete repairs on the first visit, we cannot guarantee that a fix will be permanent right away, as we work with delicate and intricate equipment. We carry a selection of universal and OEM parts on our service vans to help minimize the need for return visits. However, we are unable to stock every part for all machine types. If additional parts are needed from our warehouse or must be specially ordered, a follow-up service call fee will apply. If the machine passes all functional tests conducted by our biomedical team but the reported issue recurs, a service call fee will apply for each subsequent return visit as needed.*

I acknowledge and accept the terms outlined above regarding service call requirements, parts availability, and additional fees for subsequent visits.
I am authorized to request the above services for the upcoming service visit.*

I acknowledge
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