CareMed Endoscopy Services
"Providing Excellent Products and Service Since 1979"
Endoscope Repair Specialists
Repair Form (print and send along with repair)
Endoscopy Service844 Jury Court San Jose, CA 95112 Toll Free: 800-937-4633Fax: 408 280-1549
e-mail: service@caremedendoscopy.com website: www.caremedendoscopy.com
Date:_________________________ Total Price:________________________
Customer Name:_____________________________________________________________________________
Contact Name:______________________________________Department______________________________
Address:______________________________________________________________________________
City:________________________________________State:________________Zip:__________________
Phone______________________________________E-Mail:____________________________________
Customer Name:_____________________________________________________________________________
Contact Name:______________________________________Department______________________________
Address:______________________________________________________________________________
City:________________________________________State:________________Zip:__________________
Phone______________________________________E-Mail:____________________________________
Purchase Order#_____________________________________________
Manufacturer:_______________________________________________________________________
Equipment Type:_____________________________________________________________________
Model#:_____________________________________________Serial#_________________________
Description of Problem:________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Authorized Signature:_________________________________________________________
Print Name:_________________________________________________________________
PLEASE DISINFECT ALL EQUIPMENT BEFORE PICKUP
Call For Free Quote
CareMed Endoscopy Service
(800) 937-4633
www.CareMedendoscopy.com
CareMed Endoscopy Service
(800) 937-4633
www.CareMedendoscopy.com
