Support Request Form

1
unique id
2
Company Name* This field is required.
3
E-mail* This field is required.
example@example.com
4
Phone Number* This field is required.+233xxxxxx
5
City / Town* This field is required.
6
I am having a problem with this equipment* This field is required.Equipment Brand Name
7
Type of equipment* This field is required.
MRI
Xray
Ultrasound
Monitors/ICU
CR/DR
Other
8
Which type?* This field is required.
9
Equipment Model Name* This field is required.
10
Serial NumberPut the equipment SERIAL NUMBER
11
Error Code Put the equipment ERROR CODE
12
Error Message
13
Additional InformationDescribe Your Problem
Huge
Large
Normal
Small
Ok
Ok
14
How would you like to be contacted?
By phone
By e-mail
15
Type a question
Should be Empty: