CUSTOMER REPAIR REQUEST FORM

CUSTOMER REPAIR REQUEST FORM

Please provide the details below to submit your device for repair.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour Minutes
CUSTOMER DETAILS
Your Full Name

First NameLast Name
Phone Number
Direct Phone or Mobile (include state prefix, i.e. (03) for VictoriaFormat: (000) 000-0000.
Email Address
Hospital
Pick-up Location
Collection Address

Address Line 1

Address Line 2
CityState Post Code
DEVICE DETAILS

Feel free to add multiple devices here.
Device Model
Separate multiple item models with a '/'
Device Serial Number
Separate multiple item serial numbers with a '/'
Describe the Problem
Your description assists us to identify intermittent issues (if applicable)
FREIGHT DETAILS
Freight ready now?
Date and Time

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Length of freight (approx)
Centimetres (cm)
Width of freight (approx)
Centimetres (cm)
Depth of freight (approx)
Centimetres (cm)
Weight of freight (approx)
Kilograms (kg)
SAFETY DETAILS
Sterilised / Disinfected
Sterlisation / Disinfection Paperwork
Secured in a Yellow Biohazard Bag
Should be Empty:

CUSTOMER DETAILS