Texas Litter Control Maintenance Request
Your Name:
*
First Name
Last Name
Requestor's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Requestor's Email
*
example@example.com
Which location(s) is maintenance needed?
*
Houston Memorial Clinic
Humble Clinic
Spring Clinic
Tomball Clinic
Resale Shop
Other
What type of maintenance is required?
*
Please Select
Building Maintenance
Exterior Doors/Alarm System
Medical Equipment
Computer Equipment
Describe the urgency of the issue.
*
Please Select
URGENT! - This issue is effecting our ability to perform our job or is a safety issue.
Moderate - We really need it fixed but the problem is not mission critical.
Low - It can wait but we need it fixed.
What is broken/not working?
*
Please describe in detail where the issue is located within the clinic.
*
Please describe any actions which have already been taken to resolve this issue and if you have already contacted anyone other than submitting this request. If you have contacted someone already, who did you alert?
*
Please snap a photo of the broken item.
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