USS Parts Order Worksheet & Call Registration Form

Dealer Information
Customer Name
Dealer Name*
Reporting Technician*
Reporting Technician Phone*
Reporting Technician Email
End User Information
Country/City
Hospital/Clinic Name*
System Type*
System Serial No.*
S/W Version
Installed Date
Patient Impact*
- Impacted
- None
Issued Date
Issuer Name
RMS Registration
GSPN Service Order
System Information
* You must enter detailed information in the required fields.
Problem Type*
- H/W Problem
- S/W Problem
- Image Problem
- Exposure/Dose Issue
- Probe
If the hospital is using Trophon or not (for the probe failure)*
- Yes
- No
Disinfectant name (for the probe failure)*
Attach two pictures of the failed probe area and serial number
Max. file size: 50 MB.
Max. file size: 50 MB.
Occurence Frequency*
- Every Time
- Daily
- Weekly
- Monthly
- One Time
Description of Problem*
System Status*
Neurologica Reviewed/Confirmed By*
Please type in the name of NeuroLogica Engineer’s name who reviewed this order.
Performed Actions
Please list performed actions and date performed:
Date 1
Action 1
Date 2
Action 2
Date 3
Action 3
Date 4
Action 4
Date 5
Action 5
Replaced/Tested Parts
Please add all replaced/tested parts for this system here:
Defective Part No. 1*
Description 1*
Serial # Part No. 1*
Defective Part No. 2
Description 2
Serial # Part No. 2
Defective Part No. 3
Description 3
Serial # Part No. 3
Defective Part No. 4
Description 4
Serial # Part No. 4
Defective Part No. 5
Description 5
Serial # Part No. 5
Engineer's Opinion on Customer Status
Parts Requests
Part Number 1*
Quantity 1*
Description 1*
Need Date*
When do you need your part to arrive?
Part Number 2
Quantity 2
Description 2
Need Date
When do you need your part to arrive?
Part Number 3
Quantity 3
Description 3
Need Date
When do you need your part to arrive?
Part Number 4
Quantity 4
Description 4
Need Date
When do you need your part to arrive?
Part Number 5
Quantity 5
Description 5
Need Date
When do you need your part to arrive?
Coverage & Shipping Information
Coverage Type*
System Serial #
Dealer PO#*
Model Code
Reported Issue
Shipping Method*
Customer Tracking
Ship-To Name & Address*
City*
State*
Zip Code*
Contact Name*
Contact Phone Number*
Email for tracking information
If you would like to receive tracking information, please enter an email address.
Dealer Agent Signature*
Signature Date*
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

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Digital Radiography Forms

Ultrasound Service Forms

Ultrasound CAS/Sales Forms

Dealer Information

End User Information

System Information

Performed Actions

Replaced/Tested Parts

Parts Requests

Coverage & Shipping Information

Form Notification