PacificMedicalRepair.com – Biomedical Equipment Repair

Who is your Pacific Medical Territory Manager?*

If you are already working with a territory manager at Pacific Medical, please select their name from the dropdown above. If you do not have a territory manager please select "I don't know who my rep is" and and a territory manager will be assigned to you.

Facility Name*

Contact Name:*

Do you have a PO #?*

Yes
No, not yet.

What is your PO#?*

Please enter the name and email address of the individual we should contact in order to receive a PO#.*

Please enter your email address*

Your Contact Phone #*

Phone Extension

Please continue to the next section to complete your shipping and billing details.

Have you done business with Pacific Medical before and do you have a Pacific Medical Account ID?*

Yes & I know my account ID.
No, this is my first order.
Yes, but I don't know my account ID.

What is your Pacific Medical Account ID?*

Please enter the account ID that has been assigned to you by your Pacific Medical territory manager. If you do not know this # but have done business with us then please call us Toll Free 800.449.5328

Shipping & Billing Information

For those of you with an account ID please select yes in the previous section and then enter your ID in the required field above. If you selected NO or do not know your account ID, then you will be required to enter Shipping & Billing information in the next section.

Shipping Address*

Street AddressCityStateZip Code

If your Billing Address is different from your Shipping Address please select "No" in the next section and enter it below.

Is your Billing Address the SAME as your shipping Address?*

Yes
No

Billing Address*

Street AddressCityStateZip Code

Items to be sent in for Repair

Please select from the multiple choice items below which items you would like to send in for repair.

Please select one or more items below:*

What type of SpO2 will you be sending in for repair?*

Finger Probes
Y Probes
Extension Cables

Finger Probes Quantity?*

Y Probes Quantity?*

Extension Cables Quantity?*

What type of Fetal Transducers will you be sending in for repair?*

Philips / HP
GE / Corometrics

Philips / HP Quantity?*

GE / Corometrics Quantity?*

Which Telemetry Models will you be sending in for repair?*

M2601A with SpO2 Quantity?*

What are the M2601A with SpO2 Issues?*

Power Issue
SpO2 Issue
Signal Drop
Other

What is the issue? (if not listed above)*

M2601A without SpO2 Quantity?*

What are the M2601A without SpO2 issues?*

Power Issues
SpO2 Issue
Signal Issue
Other

What is the issue? (if not listed above)*

M2601B with SpO2 Quantity?*

What are the M2601B with SpO2 issues?

Power Issue
SpO2 Issue
Signal Drop
Other

What is the issue? (if not listed above)*

M2601B without SpO2 Quantity?*

What are the M2601B without SpO2 Issues?*

Power Issue
SpO2 Issue
Signal Drop
Other

What is the issue? (if not listed above)*

M4841 (TRX) with SpO2 Quantity?*

What are the M4841 (TRX) with SpO2 Issues?*

Power Issues
SpO2 Issue
Signal Issue
Other

What is the issue? (if not listed above)*

M4841 (TRX) without SpO2 Quantity?*

What are the M4841 (TRX) without SpO2 Issues?*

Power Issues
SpO2 Issues
Signal Issues
Other

What is the issue? (if not listed above)*

Which Module Models will you be sending in for repair?*

M1001 A/B Quantity?*

M1002 A/B Quantity?*

M1006 A/B Quantity?*

M1008 A/B Quantity?*

M1012 Quantity?*

M1016 Quantity?*

M1020 A/B Quantity?*

M1116 A/B Quantity?*

M1029 Quantity?*

M3000 Quantity?*

What are the M3000 Issues?*

What is the issue? (if not listed above)*

M3001A Quantity?*

What are the M3001A Issues?*

What is the issue? (if not listed above)*

M3015A Quantity?*

What are the M3015A Issues?*

No Power
Oclusion
Other. Please specify below.

What is the issue? (if not listed above)*

M3012A Quantity?*

Spacelabs Quantity?*

Datascope Expert Quantity?*

GE TRAM Quantity?*

Other Quantity?*

Other MMS Module Information*

Please enter the quantity and brands/models of MMS Modules you will be sending in for repair. If multiple models please separate with commas. IE: Brand name, model, qty; brand name, model, qty;

Additional O2 Blenders Information*

Please enter the quantity and brands/models of O2 Blenders you will be sending in for repair. If multiple models please separate with commas. IE: Brand name, model, qty; brand name, model, qty;

Additional Suction Regulator Information*

Please enter the quantity and brands/models of Suction Regulators you will be sending in for repair. If multiple models please separate with commas. IE: Brand name, model, qty; brand name, model, qty;

Additional Endoscopes Information*

Please enter the quantity and brands/models of SpO2 Cables you will be sending in for repair. If multiple models please separate with commas. IE: Brand name, model, qty; brand name, model, qty;

Additional Information for "Other Repairs"*

Please enter the quantity and brands/models of other equipment you will be sending in for repair, such as Infusion Pumps, Monitors, etc. If multiple models please separate with commas. IE: type of equipment, Brand name, model, qty; type of equipment, brand name, model, qty;

Have you reviewed your submission to make sure everything is correct? Are there any other comments you would like to add?*

Yes it is correct. I do not have any more comments.
Yes it is correct, but would like to add some additional comments below.

Please add any additional comments below before you submit.*

Online Repair Request Form

Shipping & Billing Information

Items to be sent in for Repair