USS Parts Order Worksheet & Call Registration Form

Dealer Information

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Customer Name

Dealer Name*

Reporting Technician*

Reporting Technician Phone*

Reporting Technician Email

End User Information

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Country/City

Hospital/Clinic Name*

System Type*

System Serial No.*

S/W Version

Installed Date

Patient Impact*

Impacted
None

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Issued Date

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Issuer Name

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RMS Registration

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GSPN Service Order

System Information

* You must enter detailed information in the required fields.

Problem Type*

H/W Problem
S/W Problem
Image Problem
Exposure/Dose Issue
Probe

If the hospital is using Trophon or not (for the probe failure)*

Yes
No

Disinfectant name (for the probe failure)*

Attach two pictures of the failed probe area and serial number

Max. file size: 50 MB.

Occurence Frequency*

Every Time
Daily
Weekly
Monthly
One Time

Description of Problem*

System Status*

Neurologica Reviewed/Confirmed By*

Please type in the name of NeuroLogica Engineer’s name who reviewed this order.

Performed Actions

Please list performed actions and date performed:

Date 1

Action 1

Date 2

Action 2

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Date 3

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Action 3

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Date 4

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Action 4

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Date 5

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Action 5

Replaced/Tested Parts

Please add all replaced/tested parts for this system here:

Defective Part No. 1*

Description 1*

Serial # Part No. 1*

Defective Part No. 2

Description 2

Serial # Part No. 2

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Defective Part No. 3

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Description 3

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Serial # Part No. 3

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Defective Part No. 4

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Description 4

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Serial # Part No. 4

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Defective Part No. 5

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Description 5

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Serial # Part No. 5

Engineer's Opinion on Customer Status

Parts Requests

Part Number 1*

Quantity 1*

Description 1*

Need Date*

When do you need your part to arrive?

Part Number 2

Quantity 2

Description 2

Need Date

When do you need your part to arrive?

Part Number 3

Quantity 3

Description 3

Need Date

When do you need your part to arrive?

Part Number 4

Quantity 4

Description 4

Need Date

When do you need your part to arrive?

Part Number 5

Quantity 5

Description 5

Need Date

When do you need your part to arrive?

Coverage & Shipping Information

Coverage Type*

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System Serial #

Dealer PO#*

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Model Code

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Reported Issue

Shipping Method*

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Customer Tracking

Ship-To Name & Address*

City*

State*

Zip Code*

Contact Name*

Contact Phone Number*

Email for tracking information

If you would like to receive tracking information, please enter an email address.

Dealer Agent Signature*

Signature Date*

Form Notification

Please send confirmation to [email protected] to submit this form.

Email Confirmation*

Enter Email Confirm Email

Email Confirmation 2

Enter Email Confirm Email

Email Confirmation 3

Enter Email Confirm Email

CAPTCHA

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Unique ID