Request A Loaner

To Request A Loaner, please complete the form below. Either Print, complete and fax to 1.905.567.5987 or simply fill in and submit. Fibertech will respond as quickly as possible to your request.

Download Form – Print Form

Please fill in form and return with equipment to be repaired:

Hospital Name*
Person to Contact about Loaner*
P.O. #:
Model #:
Manufacturer Requested:
Phone Number*:
Email Address*:
Ship To*:

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