USS Parts Order Worksheet & Call Registration Form Dealer InformationHiddenCustomer Name Dealer Name* Reporting Technician* Reporting Technician Phone*Reporting Technician Email End User InformationHiddenCountry/City Hospital/Clinic Name* System Type*Accuvix A30Accuvix XQSonoAce 9900 (4D)SonoAce 9900 (OB)SonoAce 8000LVSonoAce 8000EXSonoAce R5 (2P)SonoAce R5 (3P)SonoAce R3SonoAce X6SonoAce X4SonoAce Pico (202)SonoAce 6000-IIMysono U6SonoAce R7Mysono U5Accuvix XGLVAccuvix XGEXAccuvix V20LVAccuvix V20EXAccuvix V10LVAccuvix V10EXSonoAce X8LVSonoAce X8EXUGEOUGEO H60UGEO H60UGEP PT60UGEP HM70V7V8WS80RS80RS85HS80HS70AHS60HS50HS40HS30HM70EVOHera W10Hera I10Hera W9System Serial No.* S/W Version Installed Date MM slash DD slash YYYY Patient Impact* Impacted None HiddenIssued Date MM slash DD slash YYYY HiddenIssuer Name HiddenRMS Registration HiddenGSPN 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 numberMax. file size: 50 MB.Max. file size: 50 MB.Occurence Frequency* Every Time Daily Weekly Monthly One Time Description of Problem*System Status*Not DownPartial DownHard DownNeurologica Reviewed/Confirmed By*Please type in the name of NeuroLogica Engineer’s name who reviewed this order. Performed ActionsPlease list performed actions and date performed:Date 1 MM slash DD slash YYYY Action 1 Date 2 MM slash DD slash YYYY Action 2 HiddenDate 3 MM slash DD slash YYYY HiddenAction 3 HiddenDate 4 MM slash DD slash YYYY HiddenAction 4 HiddenDate 5 MM slash DD slash YYYY HiddenAction 5 Replaced/Tested PartsPlease 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 HiddenDefective Part No. 3 HiddenDescription 3 HiddenSerial # Part No. 3 HiddenDefective Part No. 4 HiddenDescription 4 HiddenSerial # Part No. 4 HiddenDefective Part No. 5 HiddenDescription 5 HiddenSerial # Part No. 5 Engineer's Opinion on Customer StatusParts RequestsPart Number 1* Quantity 1* Description 1* Need Date*When do you need your part to arrive? MM slash DD slash YYYY Part Number 2 Quantity 2 Description 2 Need DateWhen do you need your part to arrive? MM slash DD slash YYYY Part Number 3 Quantity 3 Description 3 Need DateWhen do you need your part to arrive? MM slash DD slash YYYY Part Number 4 Quantity 4 Description 4 Need DateWhen do you need your part to arrive? MM slash DD slash YYYY Part Number 5 Quantity 5 Description 5 Need DateWhen do you need your part to arrive? MM slash DD slash YYYY Coverage & Shipping InformationCoverage Type*WarrantyBillableContractDemoHiddenSystem Serial # Dealer PO#* HiddenModel Code HiddenReported IssueShipping Method*UPS OvernightUPS 2nd DayUPS GroundFedEx OvernightHiddenCustomer Tracking Ship-To Name & Address* City* State* Zip Code* Contact Name* Contact Phone Number*Email for tracking informationIf you would like to receive tracking information, please enter an email address. Dealer Agent Signature* Signature Date* MM slash DD slash YYYY Form NotificationPlease 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 CAPTCHAHiddenUnique ID Δ