Repair Request Form – Kansas City

Repair Request Form – Kansas City

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!

The information you provide is kept confidential and not sold or shared with any other individuals or organizations.

*Denotes Required Field.

    Kansas City Service Center

    Customer Information
    1. YesNo

      Name of contact person to receive repair estimate:

    6. How would you like to be informed of the repair estimate?
    Item To Be Repaired
    3. YesNo
      1. YesNo
    5. treatmenttherapeuticNA
    6. YesNo
    7. If yes, describe how the product malfunctioned or not performed as intended. Include the reason for the repair here:

      IF THIS IS A LOANER SCOPE THAT HAS FAILED:

    1. beforeduringor after the procedure
    2. YesNo
    3. missedaborteddelayed prolonged

      Due to Regulatory Requirements - Please provide reprocessing method

    HIGH LEVEL DISINFECT SCOPE BEFORE SHIPPING