ERS Biomedical - Repair Service Form

Please fill out completely and include with shipment. Use the Print / Save PDF button for a fixed two-page output.

Customer Information

Facility / Company Name

Contact Name

Phone

Date

Customer dropdown remembers entries saved on this device.

Billing & Shipping

Bill To (Name / Address)

Ship To / Return Address (Name / Address)

Return Shipping Method

Customer Shipping Account # (If Applicable)

Equipment Information

Manufacturer

Model

Serial Number

Accessory / Parts Included (Cables, Remotes, Power Supply, Etc.)

Problem Description / Symptoms

Service Options

Repair Evaluation / Troubleshoot Calibration Preventive Maintenance Parts Only (No Repair)

Estimate / Approval

Call for Approval Email Estimate Proceed if under $

Proceed (No Limit)

Ship To: ERS Biomedical, 11608 Perpetual Dr, Odessa, FL 33556 • 727-807-7928

Payment / Terms (If Applicable)

If you prefer not to write card info on this form, leave blank and note: “Call for payment.”

Payment Method

Card Type

Name on Card

Card Number

Exp (MM/YY)

CVV

Billing ZIP

Office Use Only

Date Received

Received By

Condition Upon Arrival

Technician Notes / Findings

Parts Used

Part #

Description

Qty

Part dropdowns include starter items and remember saved entries on this device.

Labor / Charges

Final Status

Date Shipped

Tracking #

Customer Authorization

By signing, customer authorizes ERS Biomedical to evaluate/repair as indicated above and agrees to pay approved charges.

Authorized Signature

Printed Name

Date