Depot Repair Form

PO #

Contact Person:

Phone:

E-mail address:

Facility Name:

Shipping Address:

Expedited service?
NoYes

City:

State:

Zip:

Carrier:

Tracking #

Insured Value: $

Directions for return (if Any):

For:

1. Monitoring Equipment

2. Telemetry Transmitters

3. Sam Modules/ Gas Analyzers

SHIP TO:

Clinical Technology Solutions, Inc.
1025 W. Indiantown Rd, Suite 103
Jupiter, FL 33458-6852
Phone: (877) 643-6134
Fax: (469) 729-7740

For:

1. GE Central Stations

2. GE Telemetry Servers

3. GE ApexPro Amplifiers

SHIP TO:

Clinical Technology Solutions, Inc.
1400 Moccasin Trail, Suite #10
Lewisville, TX 75077
Phone: (877) 643-6134
Fax: (469) 729-7740

Equip. Manufacturer:

Model #

Software Version:

Serial #

Channel #

Any Cables included: Yes / No

Failure:

Equip. Manufacturer:

Model #

Software Version:

Serial #

Channel #

Any Cables included: Yes / No

Failure:

Equip. Manufacturer:

Model #

Software Version:

Serial #

Channel #

Any Cables included: Yes / No

Failure:

Equip. Manufacturer:

Model #

Software Version:

Serial #

Channel #

Any Cables included: Yes / No

Failure: