SERVICE REQUEST FORM

Date

Sale Date

Serial Number*

Service Number

Rep Name

Case Tracker #

CUSTOMER

Customer #

Order #

Company*

Address*

Phone*

Contact Name*

Fax

Email*

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?

(*For customers who do not have the service agreement with Icare, $50 will be charged if service is refused after receiving the cost estimate. There is no charge if customer has the service agreement.)

Yes
No

Would you like a loaner device?

(*If yes, cost will be $95 for customers who do not have the service agreement with Icare. There is no charge if customer has the service agreement.)

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