Preventive Maintenance of Endoscopy Hospital/Surgery Center/ Clinic :__________________________________RMA: _____________ Date:_________ Address:__________________________________________Phone:__________________Fax:________________ Contact:________________________ Department:___________________________ E-mail:_________________ Model:_________________________ Serial # ________________________ Account # _____________________ Routine Service Request
Performance Concerns: Please Check Where Applicable
Comments: ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Unit has been disinfected:
YES
NO (If not, please use wrap)
Please indicate type of disinfectant used: Cidex/Cidex OPA
Gluteraldehyde
Leak Test:
Pass
Fail
Peratic Acid PA Others:_______________________________
For Expedited Service Service Agreement #
Name of person
or Purchase Order# :____________________ requesting repair ___________________ Title: ________________ Phone:________________________________ Repair Approval Signature:________________________________ Fax:_________________________________ E-mail:________________________________________________ Yes, No,
begin repair of my instrument if the service resolves the issues described above. do not begin any repairs without authorization from contact above.
Note: If the instrument repair is pre-approved, it must be accompanied by a P.O. number and a hardcopy of the actual purchase order. Shipping Recommendations: Include the soaking cap, and all applicable valves with the endoscope. Remove all accessories from the shipping case are not directly related to the service concern. Pack the contents carefully to prevent further damage to the instrument.
Terms and Conditions of Caribbean Endoscopy This RMA number is valid for 60 days. If the equipment are not received by Caribbean Endoscopy within this period of time, It will be voided without prior notification. A request for a new RMA will need to be submitted. Customer is responsible for all shipping and customs charges incurred during shipment of the product to and form Caribbean Endoscopy. The RMA repair has a warranty of 90 days from date of invoice , and covers only the original problem indicated in your previous request. In the event this repair is declined, there will be an applicable charge for evaluation/reprocessing fee of $300 plus shipping and handling. Caribbean Endoscopy will not be responsible for any damages of the equipment that occur during this shipment. MVGC/2013