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Equipment Parts & Service
HBO Chamber Service Request
Please fill out the form below for any parts and service requests, and someone from our team will reach out to you within 1-2 business days.
Center Code:
Service Request Date:
First Name:
Last Name:
User Role:
--None--
Allied Health (MA, CNA, Tech, EMT)
Center Manager (Director)
Clinical Leader (Nurse Manager)
Front Office
HBO Tech (Safety Director)
Nurse – RN
Nurse – RN/LPN
Biller/Coder - Read Only
Physician
Provider (NP, PA)
Medical Director
Other- Please specify in comments.
Phone Number:
Requestor Email:
Street Address:
Street Address 2:
City:
State/Region:
Postal Code:
HBO Equipment:
--None--
PAHI Chamber
Permied TCOM PF6000
Perry Chamber
Radiometer TCOM
Secrist 3200E
Secrist 3300E
Secrist 3300H
Secrist 3600E
Secrist 3600H
Secrist 4100H
Other
N/A
Serial Number:
Service Request or Issue Description: