PMR Logo Setting the Standards in Leadership,
Technology, Excellence, Integrity
and Workmanship

Call today! 888-833-2122

REPAIR REQUEST FORM

Ship To
Account Number
PO Number
Model
Address
Serial #
Department
   
Please provide a detailed description of the problem
Who can we contact about the equipment?
Contact Person
Contact Phone
Would you like to talk with a technical person concerning equipment?      
Would you like to schedule equipment inspection, or preventative maintenance?      
Who can approve repairs?
Name Contact Phone
PLEASE DISINFECT EQUIPMENT PRIOR TO SHIPMENT
Has this equipment been disinfected?    Yes     No     Method     
Additional Comments

Home / Products / Services / About Us / Contact Us
Send us a Tweet !
©2009 - 2010 Pacific Medical Repair
Telephone: 888-833-2122