Receiving Form #19
Date
Personal data
Facility Name
Department
Contact Name
Phone
Email
Address
Unit
City
Province
Postal Code
Fax
Order
Make
Model #
Serial Number
Customer P.O. #
Picture of device
Description of Issue
Priority Level
Select..
Standard (S)
Under Warranty (W)
Under Contract (C)
Rework (R)
Ship Via
Select..
Drop Off
Canada Post
Purolator
Fedex
Other
Shipping Company
Tracking Number
Please process all equipment through the appropriate infection control procedures before shipping
Form 19d - Rev. A
Submit