Report no. :
(To be assigned in by
Manufacturer)
Please print or type or fill in by MS Word, all sections a. – i. Fax or e-mail to your supplier. Please use
repair order when reporting repairs not associated with complaints.
For claims please specify :
Purchase Date
Description of Incident/Problem: 1) What, 2) How?
When? In connection with: 1) transport, 2) unpacking,3) preparing, 4) test, 5) cleaning, 6) normal use, 7) training,
8) disassembly, 9) assembly,10) storage, 11) other:
Info on the product, prior to problem,
Storage: 1) stock, 2) site of use, 3) packed, 4) unpacked, 5) softpack, 6) other:
Used cleaning and disinfecting agents/Sterilizing method:
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