12-Month Warranty on all Repairs 24-Month Warranty on all Overhauls.

M.D Equipment Service Request Form

M.D. Endoscopy Service Request Form
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Service Agreement Customer? Yes No
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Service type: Endoscope Electronics Accessories Other

Model No. Serial No.

1 Reprocessing Verification
Medical equipment that comes into contact with potentially infectious materials must be decontaminated (cleaned, and then disinfected
or sterilized, as appropriate) before being sent to MD Endoscopy Inc. Customers are responsible for complying with applicable federal,
state, and local laws and regulations regarding decontamination of medical equipment. Please verify that the equipment has been:

cleaned AND disinfected, and/or sterilized prior to shipment

(initial) (initial)

2 Problem Description
To help investigate, please be specific:

Did this occur during a procedure? Yes No Unknown

Did the endoscope pass leak test? Yes No Unknown

3 Facility Information

Facility Name: Department:

Street Address:
City: State: Zip:

4 Contact Information

Name of person to contact about repair:

Title:
Phone: ( ) Extension: Fax: ( )

For Expedited Service

If using a purchase order, M.D. Endoscopy Inc. is Up to $500 Up to $1,000 Up to $1,500

Up to $2,500 Up to $4,000 Up to $5,000
authorized to complete your repair up to and including the
Other preapproved amount $_____________________________________
amount indicated:

Service Agreement No. or Purchase Order No.

Name of person approving repair: Title:
Approving Signature:
MDI Version 1.6B

Phone: ( ) Extension: Fax: ( )

E-mail:

810 Fentress Ct. #110 Daytona Beach, FL. 32117

1-800-866-ENDO (3636) Fax: 386.675.6902
www.MDendoscopy.com