Endoscope Service Request

Acct Name_________________________________________________

Address____________________________________________________

Contact Name _____________________Phone #__________________

Scope information Flex____	Rigid____

Brand and model # (if known)_____________________________Serial #_____________

Service Issue__________________________________________________

_____________________________________________________________

Shipped in Original Case Yes__ No__

Please do not ship any accessories with scope such as leak testers,fiber optic cables or adapters

All scopes must be sterile processed before shipping to our facility.

Please FAX form PRIOR to Shipping to . . . 770-425-2337

“RIGID” Repair Facility	“FLEXIBLE” Repair Facility

SE Surgical/IME	SE Surgical/DEES

1478 Harmony Grove Church RD	950 Eagles Landing Parkway

Auburn, GA 30011	Suite 143

Stockbridge, Ga 30281

Rep Contact: All-Star Ventures, INC - 126 Brierley Way – Carmel, IN 46032

Steve Shepherd @ 317-695-6885 / shep4604@aol.com

Shipping Instructions________________________________________

3636 Old Stilesboro Rd Kennesaw, GA 30152 Phone 770-919-7151

Fax 770-425-2337