CUSTOMER COMPLAINT
PT INTERSKALA MEDIKA SOLUSINDO
Institution Name
*
Example : RS Lorem Ipsum
PIC ( Person in charge for the Institution )
*
First Name
Last Name
Institution Address
*
Street Address
Street Address Line 2
City
Province
Zip Code
PIC Email
*
example@example.com
Phone Number
*
Please enter a valid phone number
Transaction Name ( Based on official Purchase Order )
*
Example : Pengadaan BSC RS X
Purchase Order Number
*
Warranty Card Number ( Given by IMS engineer )
*
End Of Warranty Card
-
Month
-
Day
Year
Unit Serial Number
*
if it's not available, please write "N/A"
Complaint Details
Supporting Document
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