Repair Request Form
Date
Personal data
Facility Name
Department
Contact Name
Phone
Address
Unit
City
Province
Postal Code
Fax
Order
Make
Model #
Serial Number
Customer P.O. #
Picture of device
Description of Issue
Warranty/Contract/Courtesy
Select..
Standard
Under Warranty
Under Contract
Courtesy
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