Request A Repair

To Submit a Repair Request, 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*
Vendor
Person to Contact about Repair*
Person to Approve Repair
Department:
P.O. #:
Type of Equipment:
Model #:
S/N #:
The Problem Is:
Phone Number*:
Email Address*:
Is a loaner required?:  Yes No

Please Disinfect equipment prior to shipping

HAS THIS EQUIPMENT BEEN DISINFECTED?  Yes No
Method of Disinfection:
Request A Loaner

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