DEPOT REPAIR FORM

PO #

Contact Person:

Phone:

E-mail address:

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Shipping Address:

Expedited service?
NoYes

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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: (972) 499-1306

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: (972) 499-1306

Equip. Manufacturer:

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Software Version:

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Any Cables included: Yes / No

Failure:

Equip. Manufacturer:

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Software Version:

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Any Cables included: Yes / No

Failure:

Equip. Manufacturer:

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Software Version:

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Channel #

Any Cables included: Yes / No

Failure:

Equip. Manufacturer:

Model #

Software Version:

Serial #

Channel #

Any Cables included: Yes / No

Failure: