Facility Name Attention Department Address line1 Address line2 City State Zip Model Serial Number Leak Test PassFail Comment Image Quality GoodPoor Comment Is this equipment being sent in for a Service Contract maintenance checkup? YesNo Service Issue Disinfection Method: cidex-opaGluteraldehydeSteris Other I certify this equipment has been properly reprocessed as indicated above: yesno Name Date Contact person authorized to approve service charges Email Phone or Fax Name Dept Ext The best time to reach this person is between Am/Pm to Am/Pm Contact person who can answer questions related to this Service Request. Name Dept Phone or Fax Ext The best time to reach this person is between Am/Pm to Am/Pm Purchase Order Number Not to exceed $ To expedite this Service Request, please consider the following indicating your choice: YES, begin repairs if the estimate matches the details outlined above and the charges are less than $500. YES, begin repairs if the charges are less than $ _(please indicate dollar amount). NO, do not begin repairs without our authorization, please call first Note: If you have elected to pre-approve this Service Request, a valid PO number is required.