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Fundus Imaging Systems
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Products
Fundus Imaging Systems
iCare EIDON
iCare EIDON AF
iCare EIDON FA
iCare DRSplus
Perimeters and Microperimeters
iCare COMPASS
iCare MAIA
Hand-held Tonometers
iCare IC200
iCare IC100
iCare TA01i
iCare HOME2
iCare HOME
iCare CLINIC
News and events
ABOUT US
Clinical information
Find Your Rep
Blog
Clinic login
Order probes
Tonometry Service Request Form
Date
MM slash DD slash YYYY
Sale Date
MM slash DD slash YYYY
Serial Number
*
Service Number
Rep Name
Case Tracker #
CUSTOMER
Customer #
Order #
Company
*
Address
*
Street Address
City
State *
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Armed Forces Americas
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State
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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
E01
E02
E03
E04
E05
E06
E07
E08
E09
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.