MicroMed Repair Order Form

* denotes required fields
Person to Approve Repairs
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.
Date:	PO:	(Attach if Necessary)

Manufacturer:
Model:	Serial Number:

Problem with Instrument:
Misc. Items Sent with Instrument:

Facility Name:
Street Address:
City, State, Zip:

Name:
Phone:	Fax:

Contact Person Familiar with this Equipment
Name:
Phone:	Fax:

This form authorizes MicroMed to complete any repair up to and including the amount indicated:
Quote Type:
This instrument has been properly cleaned, disinfected or sterilized using:	If other, please specify what:
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.