Service Request Form 2

Service Request Form

Venture Medical ReQuip

For Urgent Service Needs, Please Call:

800-627-3215 or 813-740-8640

1. If equipment repair is requested, only one repair service request per submission will be processed. Submit one form for each item for which you need repair service.

2. Items with an * are required to process.

3. Venture Medical reserves the right to deny any service request that is not within our range of services.
Type of Service Requested

Select all that apply
Equipment RepairPerformance EvaluationPreventative MaintenanceElectrical Safety TestingOutlet TestingOther
Please enter equipment information below if you are in need of repair service. If you need safety testing, outlet testing, preventative maintenance, performance testing, or any other service, please enter your contact information in the 'Customer Details' section and add comments in the 'Notes' field (at bottom of this form) that best describes what service is needed.
Product Information

If 'Equipment Repair' Selected
Product MFG
Product Model
Product Serial #
Type NA if you cannot locate SN
Describe the issue(s)
Please be as detailed as possible
How long has this issue been happening?
Has any other company/individual attempted to repair?
Image/ Picture

Cancelof
Helpful Hint for uploading images:

If you are filling this form out on a desktop and want to add a photo from your mobile device, simply save the form (button at bottom of form). An email will be sent to the email address you provided that will have a link to continue your submission. Open the email with your mobile device, click on the link, and then you may scroll to the image upload section to complete the submission.
Customer Details
Company Name*
Contact Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Notes/Other Details
Please submit any useful information here
You will typically receive a reply within 1 business day (excluding weekends and holidays). If you require emergency service, or if this is an urgent request, please call 800-627-3215 or 813-740-8640.

You will receive a confirmation email shortly after submission. If you do not receive a confirmation within 15 minutes, please try again, or use our general contact form.
Should be Empty:

Service Request Form

Type of Service Requested

Product Information

Customer Details