Service/Return Notification

Fujinon logo Please contact your customer Care Associate at 1-800-385-4666 to obtain your RMA number before returning your scope for service.

Reprocessing Method: I certify this equipment has been re-processed as indicated below:
RMA Number:		Issued by:
In order to facilitate the service of your scope, please return a completed copy of this form with the equipment and keep a copy for your records. Download copy here.

Facility Name:
Attention:
Department:
Address Line 1:
Address Line 2:
City, State and Zip

Model:		Serial Number:
Leak Test:	Pass Fail	Comment:
Image Quality:	Good Poor	Comment:
Is this equipment being sent in for a Service Contract maintenance checkup?			Yes No
Service Issue:

Do you consider this a Complaint as defined by FDA – GMP's - 21 CFR 820.198:			Yes No

Cidex OPA Gluteraldehyde Other
Custom Ultrasonics Medivator Steris J&J
Name:		Date:
NOTICE: In the event where the returned scope has not been re-processed, Fujinon reserves the right to charge the customer a $150.00 Re-processing Fee. This amount will be added to the cost of repairs.

If the above cleaning information is not filled in, MicroMed assumes the scope has not been properly cleaned, and will assess cleaning fee of $150.00. If you elect to pre-approve this service request, a valid P.O. number is required.

Contact person authorized to approve service charges
Name:		Dept:
Phone:		Fax:
The best time to reach this person is:
Contact person who can answer questions regarding this Service Request
Name:		Dept:
Phone:		Fax:
The best time to reach this person is:

Purchase Order Number:
This form applies to all scopes. (Customer/Loaner/Demo/Evaluation Scopes)