Service Request Form "*" indicates required fields Service Request NumberSelect Product Type From the Options Below*Please Select an OptionMaskMachinePartsBatteryLuminOtherPlease Enter the Product Brand*e.g. ResMed, Philips, etc…Please Enter the Product Name*e.g. ResMed Airsense 11 Autoset etc..Select Battery Type From the Options Below*Please Select an OptionMedistrom Pilot Lite 12VMedistrom Pilot Lite 24VMedistrom Pilot FlexZopec Explore MiniZopec Explore 5500Contact Details for the Pharmacy Representative* Full Name Pharmacy Name*Email Address* Phone NumberPlease Upload Proof of PurchaseMax. file size: 64 MB.Date of Purchase* DD slash MM slash YYYY Date When Problem Occurred* DD slash MM slash YYYY Please Enter The Full Name of The Patient* First Last Please Provide Detailed Information to Help Us Better Understand the Problem*e.g. Torn, broken, leaking, data loss, unusual noises, unresponsive touchscreen, power supply problem, or device not turning on.Is the Product Visibly Broken?* Yes No Please Attach a Photo of the Issue*Max. file size: 64 MB.What Troubleshooting Have You Done Already?*e.g. Restarted the device, checked power connections, followed steps in the user manual, etc.Was There Any Adverse Event While Using this Product?* Yes No An adverse event is any undesirable experience associated with the use of a medical product with a patient, resulting in one of this following: Death Life threatening Hospitalisation (initial or prolonged) Disability or permanent damage Required intervention to prevent permanent impairment Injury likely if malfunction were to reoccur Other serious (important medical events)Part Number/Device Model?*Device Serial Number?*Is the Product Registered for Extended Warranty?* Yes No Is the Battery Within the Warranty Period?* Yes No Enter the Warranty Code*Does the Device Display an Error Code?* Yes No Enter the Error Code*Has the Device Been Dropped?* Yes No Has the Device Had Water Spilled On it?* Yes No Has the Patient Previously Made a Request Within the Last Year?* Yes No Does the Battery Trigger or Short the AC Wall Plug / PSU When Plugged in to Charge?* Yes No When the DC Cable is Plugged into the DC Port, Does the Battery Beep While Flashing Blue Lights?* Yes No CPAP Machine Model?*e.g: ResMed AirSense 10, Philips Dreamstation GoAny Beeping Alarm with Blue Light Flashing From the Battery When Plugged Into the AC wall Plug or PSU?* Yes No Date of Last Full Cycle* DD slash MM slash YYYY Date of Last Full Charge* DD slash MM slash YYYY PAP Device Make*e.g: ResMed, Philips etc.PAP Device Model*e.g: AirSense 10 etc.PAP Mode of Operation*e.g: CPAP, APAP, etc.Therapy PAP Pressure*Ref Number*Located on the back or bottom of the PAP deviceMask Type*e.g: Nasal Pillow, Nasal etc.Heated Humidifier Setting*Heated Tubing Setting*EPR Setting*Exhalatory Pressure Relief SettingWhen returning the device for servicing, repair or investigation, I confirm that the patient has been notified in writing that as part of that process their user-generated data and configuration settings may be viewed, modified or cleared.* I confirm that the patient has been notified about potential access to their data during service or repair.When returning the device for servicing, repair or investigation, I confirm that the patient has been notified in writing that as part of that process their user-generated data and configuration settings may be viewed, modified or cleared.Please Provide any Extra Information if NecessaryNameThis field is for validation purposes and should be left unchanged.
