Pre-visit On-site Servicing Questionnaire

Please complete this form and send it to us and we will provide you with a quotation to service your medical equipment on-site.

Surgery name:
Address:
Postcode:
Customer ID Num:
Contact Name:
Telephone:
Fax:
Email Address:
Service Month: (please inform us when your service is due)

Items for On-site Servicing

Please enter quantity in the box provided. If zero, please leave blank.

ECG Machine
Defibrillator
Spirometer
Manual BP Monitor
Electronic BP Monitor
24 Hour BP Monitor
Scales
Nebulizer
Pulse Oximeter
CO Monitor/Smokalizer
Fridge
Doppler
Suction Pump
Thermometer
Vital Signs Monitor
Centrifuge
Ear Syringe
Cautery- medical safety
check only