Repair Order Form

Please fill out a form below with all repair information.

    Date

    Facility or Customer Name

    Customer Shipping Address

    City

    State:

    Zip

    Contact Person

    Email

    Phone

    Fax

    Purchase Order Number (fill in N/A if not applicable)

    Item or Model Number (fill in N/A if not applicable)

    Serial Number (fill in N/A if not applicable)

    Description of Problem

    Special Instructions

    Reminder: After you hit send, you will receive an emil with all the information you have entered into this form. Please print that email and include the print out in the box along with the device(s) requiring repair.

    Please ship your package and Repair Order Form to the following address:

    Surgical Medical Supplies
    6223 Highland Place Way
    Suite 201
    Knoxville, TN 37919 USA

    Phone: 1.865.607.9233