Repair Request Form

Click Here for a PDF version of our Repair Request Form, which you may fax or mail to us.

If you prefer to fill out a Repair Request Form on-line you can do so below!

Specialty Medical Systems collects personal information only at a visitor’s request. The information you provide is kept confidential and not sold or shared with any other individuals or organizations.

*Denotes Required Field.


Customer Information
Billing Information
  1. YesNo
  2. Name and phone# of person to approve repair cost and/or provide PO#:

Item To Be Repaired
  1. YesNo
HIGH LEVEL DISINFECT SCOPE BEFORE SHIPPING
  1. YesNo
  2. YesNo
  3. YesNo