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 SMS Repair Department
Source Management SMSW Continuing Education
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About SolutionPros

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

*Facility Name:

*Name: *E-mail Address:
Department: *Telephone
Street: Fax
City:
State: Zip:
 


Billing Information

Is PO# required? Yes No P.O.#
Name and phone# of person to approve repair cost and/or provide PO#:

 

Items To Be Repaired
     Need Loaner?
1. Mfg. & Model #
1. Serial #
2. Mfg. & Model #
2. Serial #
3. Mfg. & Model #
3. Serial #
4. Mfg. & Model #
4. Serial #
5. Mfg. & Model #
5. Serial #

 

Comments:

DISINFECT OR STERILIZE EQUIPMENT BEFORE SHIPPING!!!

This scope may be leaking
This equipment has been disinfected
This equipment has been sterilized