Request for Repairs and Patient Privacy Agreement
Date: YYYY/MM/DD
【Customer Information】
【Product Information】
Product name
Software version
S/N
Symptom
Stored item
□ None □ Main unit □ HDD □ DVD/CD
□ USB □ Photo □ Other ( )
Outsourced product
□ None
□ Provide details if applicable ( )
【Administration】
Handling date YY MM DD
Customer service
representative
※ Please sign inside the box below if you agree to the following:
□ Data saved on memory devices of products being repaired (e.g., hard disks) may become
lost during tests and repairs.
□ Data saved on a product being repaired must be backed up by the customer.
□ Samsung will not be held responsible for any loss of data not backed up.
□ Samsung Medison does not use patient information for unauthorized purposes, modify
such information, or provide it to third parties.
【Customer Signature】
I entrust my product to ( ) for repair and agree to the policies above.
Hospital
Handler
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