SERVICE REQUEST FORM

 

Please fill out the following information and one or our representatives will contact you to arrange for the service of your equipment. 

American Express, Master Card, Visa or Discover cards can be used to pay for your repaired or calibrated equipment at any R-Wave location. You may prepay your order, however using your credit card will ensure the fastest processing and will result in you receiving your equipment sooner!

Note: A fee of $100. will be charged for all estimates of repairs.  This fee will go towards the service invoice if you approve the estimate.

 

   Facility Name:
   First Name:
   Last Name:
   Address:
   City:
   State:      Zip:
   Email:
   Telephone: ext.:
   Fax:

 
  

How did you hear about us?:
  

 

Referral from:
Direct Mail
Fax Advertisement

Advertisement:
EMS
JEMS
Medical Equipment
Plastic Surgery
Medical Dealer


Other Advertisement:

 
About Your Equipment
Manufacturer:
Model #:

Serial #:

Accessories Included:

 
Type of service:

Repair
Calibration
Regular Maintenance

Other:  

 

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