Equipment Service Request Form

Complete ENTIRE FORM below. We will contact you with a quote and an estimated turnaround time. To expedite service, pre-authorize your repairs up to a specified dollar amount. For assistance, please contact us at (412)281-4186 or via email: Repair@surgicalproductsolutions.com. We are unable to initiate a repair without a Purchase Order number. If a return shipping account number is not provided on this form, the cost of shipping will be added to your final invoice. Payment is NET 30 unless otherwise specified.

General

Reprocessing

Medical Equipment that comes into contact with potentially infectious materials must be decontaminated (cleaned, disinfected, or sterilized, as appropriate) before being sent to Surgical Product Solutions. Customers are responsible for complying with applicable federal, state, and local laws and regulations regarding decontamination of medical equipment. If the equipment has not been decontaminated, an $150 charge will be added to the final repair invoice.

Problem Description

Ship To

Bill To:

Pre-Approval

SPS is authorized to complete your repair up to and including the amount indicated:

Approval Signature

Use your mouse to sign above the line. *

Submit

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REMINDER: PURCHASE ORDER NUMBER MUST BE PROVIDED WITH THIS FORM

Ship Equipment Including Form To:

SPS Repair 2340 Stock Creek Blvd. Rockford, TN 37853

Phone: 412-281-4186 Fax: 412-774-2345

repair@surgicalproductsolutions.com

Thank you for choosing Surgical Product Solutions. Ask us about our Repair/Exchange Program!