V59 Loaner Request Report – Samsung Healthcare USA

Dealer Information

* or required Indicate Required Fields
You must enter detailed information in the required fields.

Dealer*

Submitter's Name*

Submitter's Phone*

Submitter's Email*

System Information

User's Name

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User's Phone

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User's Email

Hospital/Clinic Name*

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Country/City

Install Date

System Type*

System S/N*

System S/W

System Status*

Coverage Type*

UltraSound Probe*

UltraSound Part Number*

Probe Serial Number*

Defect Category*

Physical Damage
Drop Out
Image Quality

Frequency of issue*

Constant
Intermittent

Probe*

Are you requesting a probe?

Yes
No

To Loaner Ship to Address*

If you are requesting a Loaner, enter ship-to address. If you are not requesting a Loaner, put N/A.

Details*

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Detector Front Photo

Please attach detector front photo:

Max. file size: 50 MB.

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Front Photo Remarks

Photo Information

Detector Back Photo

Please attach photo of detector s/n from behind battery

Max. file size: 50 MB.

Back Photo Remarks

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#1 [Left Up]

Attach shock sensor photo

Max. file size: 50 MB.

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#1 sensor

normal
break

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#2 [Right Up]

Attach shock sensor photo

Max. file size: 50 MB.

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#2 sensor

normal
break

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#3 [Right Down]

Attach shock sensor photo

Max. file size: 50 MB.

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#3 sensor

normal
break

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#4 [Left Down]

Attach shock sensor photo

Max. file size: 50 MB.

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#4 sensor

normal
break

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Engineer's Comments

Signature

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Main Connector

Attach Main Connector Photo:

Max. file size: 50 MB.

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Main Connector Remarks

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Battery Connector

Attach Battery Connector Photo:

Max. file size: 50 MB.

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Battery Connector Remarks

Engineer's Signature*

Date signed*

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

Unique ID