Depot Repair Form

Rapid Turnaround · Competitive Flat Rates · 90-Day Warranty

Ship Your Equipment To

Clinical Technology Solutions, Inc.
1400 Moccassin Trail, Suite #10
Lewisville, TX 75077
Phone: 877-643-6134

Facility

PO #
Contact Person *
Phone *
E-mail Address *
Facility Name *
Shipping Address *
City *
State *
Zip *
Expedited Service?

Shipping

Carrier
Tracking #
Insured Value ($)
Directions for Return (if any)

Equipment #1

Equipment Manufacturer
Model #
Software Version
Serial #
Channel #
Cables Included?
Failure Description

Equipment #2 (optional)

Equipment Manufacturer
Model #
Software Version
Serial #
Channel #
Cables Included?
Failure Description

Equipment #3 (optional)

Equipment Manufacturer
Model #
Software Version
Serial #
Channel #
Cables Included?
Failure Description

Equipment #4 (optional)

Equipment Manufacturer
Model #
Software Version
Serial #
Channel #
Cables Included?
Failure Description
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