SERVICE REQUEST FORM

Today's Date

Sale Date

Serial Number*

Service Number

Rep Name

Case Tracker #

CUSTOMER

Customer #

Order #

Company*

Address*

Phone*

Contact Name*

Fax

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Please check the appropriate box

Dropped Device
Measurement results are too low
Measurement results are too high
Measurement results are inconsistent
Probe moves sluggishly or doesn't move at all
Device constantly warns about low battery
Other

The following error message(s) appears frequently

Other

Would you like a cost estimate for service?

Cost estimates are performed at no charge if you have a service agreement with iCare. If you do not have a service agreement, a $50 fee will be charged if service is refused after receiving the estimate.

Yes
No

Would you like a loaner device?

If yes, loaner devices are provided at no charge if you have a service agreement with iCare. If you do not have a service agreement with iCare a $95 fee will be charged for the loaner device.

Yes
No

Consent*

I understand that I am responsible for the full cost of the loaner tonometer should it be damaged, lost, or not returned.

Tonometry Service Request Form

CUSTOMER