Confirm decontamination of Items which will be returned (only touch interfaces/ consoles) Note: Failure to do so will lead to an additional decontamination fee

Disinfection has been carried out (non-contaminated product) Contaminated product (expense allowance) Non-contact part / not required

Was a Patient or User's safety at risk due to this failure?

Yes No

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Additional Comments

Customer's Bill To Information

(To send repair invoice)

Billing Company Name

Billing Address

Billing City

Billing State

Billing Country

Customer's Ship To Address

(To send the repaired product)

Same as Billing

Shipping Company Name

Shipping Address

Shipping City

Shipping State

Shipping Country

Customer's Carrier Information

(To return the repaired product)

Shipping Carrier

Level of Ship

Ship Account Number

Customer Primary Contact

Name

Phone

스펠만 고전압 뉴스레터를 구독하세요

분기마다 발행되는 스펠만 고전압 뉴스레터를 구독하세요. 고전압전원장치에 대한 기술 정보와 최신 업계동향을 전달하여 드립니다.

당신의 이름

귀하의 이메일

장소