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Equipment Parts & Service
Chair & Other Equipment 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.
Blue Book Code
*
This is the code that includes your state abbreviation followed by three numbers.
Service Request Date
*
First name
*
Last name
*
Role in the Center
*
Please Select
Center Manager
Clinical Leader
Front Office
HBO Tech
Nurse - RN
Other- Please specify in comments.
Provider (NP, PA)
Phone number
*
Email
*
Street address
*
Street address 2
City
*
State/Region
*
Postal code
*
Equipment Chairs/ Exam Table Model
Please Select
MTI Chair 527
MTI Chair 529
Midmark Chair 416/417
Midmark Chair 646/647
Amerimedica Bariatric Exam Table
Other
N/A
Chair Width
Please Select
Standard (S)
Wide (W)
Other
Chair Color
Please Select
Blue Ridge
Gun Metal
Taupe
Green
Other
Location of Defect
*
Right Arm Upholstery
Left Arm Upholstery
Back/Seat Upholstery
Foot Upholstery
Foot Control
N/A
Serial Number
*
Service Request or Issue Description
*
Please describe the issues you are experiencing with your equipment. Be sure to address any "Other" or "N/A" selections.
Equipment Image(s)
