Defective Detector Report (Samsung) Dealer Information* or required Indicate Required FieldsYou must enter detailed information in the required fields.Dealer*Submitter's Name*Submitter's Phone*Submitter's Email* Return Name & Address*Where do you want the detector sent after repair?GSIS Ticket #*System InformationUser's NameUser's PhoneUser's Email Hospital/Clinic Name*Country/CityInstall Date System Type*System S/N*System S/WSystem Status*Not DownPartial DownHard DownCoverage Type*WarrantyDrop CoverageContractBillableDetector Type*Detector Part Number*Detector S/N*Detector F/WDefect Category* Physical Damage Connection Issue Image Quality Frequency of issue* Constant Intermittent Conditions* Wired (tethered) Wireless Loaner*Are you requesting a loaner? Yes No 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*Detector Front PhotoPlease attach detector front photo:Max. file size: 50 MB. Front Photo Remarks Photo Information Detector Back PhotoPlease attach photo of detector s/n from behind batteryMax. file size: 50 MB. Back Photo Remarks#1 [Left Up]Attach shock sensor photoMax. file size: 50 MB. #1 sensor normal break #2 [Right Up]Attach shock sensor photoMax. file size: 50 MB. #2 sensor normal break #3 [Right Down]Attach shock sensor photoMax. file size: 50 MB. #3 sensor normal break #4 [Left Down]Attach shock sensor photoMax. file size: 50 MB. #4 sensor normal break Engineer's Comments Signature Main ConnectorAttach Main Connector Photo:Max. file size: 50 MB. Main Connector RemarksBattery ConnectorAttach Battery Connector Photo:Max. file size: 50 MB. Battery Connector RemarksEngineer's Signature*Date signed* 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 Unique ID Δ