To help us better serve you, Please Print out this Form, and Fill out Completely. 
Please include this form with instrument when shipped.      

Date______/______/______ P.O. #___________________(Please attach copy)

Model________________________ Serial #____________________________

Problem with Instrument___________________________________________

_________________________________________________________________

Misc. Items in Case________________________________________________

               • Please disinfect all instruments before sending for repair •

Shipping Address:

Hospital/ Clinic Name ______________________________________________

Street Address ____________________________________________________

City, State, ZIP ___________________________________________________

Billing Address:

Hospital/ Clinic Name ______________________________________________

Street Address ____________________________________________________

City, State, ZIP ___________________________________________________

Person to Approve Repairs:     E-Mail Address:________________@_______

Name___________________________ Phone #_________________________

Contact Person Familiar with this Equipment: 

Name___________________________ Fax #___________________________

Credit Card No.________________________________ Expiry Date: _______

Ship to:  Endoscope Repair Inc. 5757 Blue Lagoon Drive, Ste. 235 Miami, Florida 33126  USA