Test form

First Name

Last Name

Company Name

Email

Phone

Address

City

State/Province

Zip

Purchase Order #

Manufacturer

Abbott (Hospira) Model

Baxter (Travenol) Model

CareFusion (Alaris) Model

Coventrus Model

Masimo Model

Medfusion Model

Nellcor Model

Physio Control Model

Practivet Model

Triumph Model

VetOne Model

Zoll Model

If other manufacturer, please specify:

If other model, please specify:

Serial Number

IV Set Being Used

Syringe Brand Being Used

Please describe the issue:

Please list all accessories that you are shipping with the equipment:

Upload a photo of the damaged equipment (optional):

Maximum file size: 52.43MB

Add another piece of equipment?

Yes

No

Manufacturer

Abbott (Hospira) Model

Baxter (Travenol) Model

CareFusion (Alaris) Model

Coventrus Model

Masimo Model

Medfusion Model

Nellcor Model

Physio Control Model

Practivet Model

Triumph Model

VetOne Model

Zoll Model

If other manufacturer, please specify:

If other model, please specify:

Serial Number

IV Set Being Used

Syringe Brand Being Used

Please describe the issue:

Please list all accessories that you are shipping with the equipment:

Upload a photo of the damaged equipment (optional):

Maximum file size: 52.43MB

Add another piece of equipment?

Yes

No

Manufacturer

Abbott (Hospira) Model

Baxter (Travenol) Model

CareFusion (Alaris) Model

Coventrus Model

Masimo Model

Medfusion Model

Nellcor Model

Physio Control Model

Practivet Model

Triumph Model

VetOne Model

Zoll Model

If other manufacturer, please specify:

If other model, please specify:

Serial Number

IV Set Being Used

Syringe Brand Being Used

Please describe the issue:

Please list all accessories that you are shipping with the equipment:

Upload a photo of the damaged equipment (optional):

Maximum file size: 52.43MB

Add another piece of equipment?

Yes

No

Manufacturer

Abbott (Hospira) Model

Baxter (Travenol) Model

CareFusion (Alaris) Model

Coventrus Model

Masimo Model

Medfusion Model

Nellcor Model

Physio Control Model

Practivet Model

Triumph Model

VetOne Model

Zoll Model

If other manufacturer, please specify:

If other model, please specify:

Serial Number

IV Set Being Used

Syringe Brand Being Used

Please describe the issue:

Please list all accessories that you are shipping with the equipment:

Upload a photo of the damaged equipment (optional):

Maximum file size: 52.43MB

Add another piece of equipment?

Yes

No

Manufacturer

Abbott (Hospira) Model

Baxter (Travenol) Model

CareFusion (Alaris) Model

Coventrus Model

Masimo Model

Medfusion Model

Nellcor Model

Physio Control Model

Practivet Model

Triumph Model

VetOne Model

Zoll Model

If other manufacturer, please specify:

If other model, please specify:

Serial Number

IV Set Being Used

Syringe Brand Being Used

Please describe the issue:

Please list all accessories that you are shipping with the equipment:

Upload a photo of the damaged equipment (optional):

Maximum file size: 52.43MB

Add another piece of equipment?

Yes

No

Manufacturer

Abbott (Hospira) Model

Baxter (Travenol) Model

CareFusion (Alaris) Model

Coventrus Model

Masimo Model

Medfusion Model

Nellcor Model

Physio Control Model

Practivet Model

Triumph Model

VetOne Model

Zoll Model

If other manufacturer, please specify:

If other model, please specify:

Serial Number

IV Set Being Used

Syringe Brand Being Used

Please describe the issue:

Please list all accessories that you are shipping with the equipment:

Upload a photo of the damaged equipment (optional):

Maximum file size: 52.43MB

Add another piece of equipment?

Yes

No

Manufacturer

Abbott (Hospira) Model

Baxter (Travenol) Model

CareFusion (Alaris) Model

Coventrus Model

Masimo Model

Medfusion Model

Nellcor Model

Physio Control Model

Practivet Model

Triumph Model

VetOne Model

Zoll Model

If other manufacturer, please specify:

If other model, please specify:

Serial Number

IV Set Being Used

Syringe Brand Being Used

Please describe the issue:

Please list all accessories that you are shipping with the equipment:

Upload a photo of the damaged equipment (optional):

Maximum file size: 52.43MB

Add another piece of equipment?

Yes

No

Manufacturer

Abbott (Hospira) Model

Baxter (Travenol) Model

CareFusion (Alaris) Model

Coventrus Model

Masimo Model

Medfusion Model

Nellcor Model

Physio Control Model

Practivet Model

Triumph Model

VetOne Model

Zoll Model

If other manufacturer, please specify:

If other model, please specify:

Serial Number

IV Set Being Used

Syringe Brand Being Used

Please describe the issue:

Please list all accessories that you are shipping with the equipment:

Upload a photo of the damaged equipment (optional):

Maximum file size: 52.43MB

Add another piece of equipment?

Yes

No

Manufacturer

Abbott (Hospira) Model

Baxter (Travenol) Model

CareFusion (Alaris) Model

Coventrus Model

Masimo Model

Medfusion Model

Nellcor Model

Physio Control Model

Practivet Model

Triumph Model

VetOne Model

Zoll Model

If other manufacturer, please specify:

If other model, please specify:

Serial Number

IV Set Being Used

Syringe Brand Being Used

Please describe the issue:

Please list all accessories that you are shipping with the equipment:

Upload a photo of the damaged equipment (optional):

Maximum file size: 52.43MB

Add another piece of equipment?

Yes

No

Manufacturer

Abbott (Hospira) Model

Baxter (Travenol) Model

CareFusion (Alaris) Model

Coventrus Model

Masimo Model

Medfusion Model

Nellcor Model

Physio Control Model

Practivet Model

Triumph Model

VetOne Model

Zoll Model

If other manufacturer, please specify:

If other model, please specify:

Serial Number

IV Set Being Used

Syringe Brand Being Used

Please describe the issue:

Please list all accessories that you are shipping with the equipment:

Upload a photo of the damaged equipment (optional):

Maximum file size: 52.43MB

If you have more than 10 items, please fill out a separate form. Thank you!

Is authorization required before service is performed?

Yes

No

How fast is shipping required?

Ground

3rd day **

2nd day air **

Next day air **

** These options will incur an additional fee. Please call for details.