To request service, complete this form. Required fields marked with an asterisk (*)
 
Contact Name: *
   
Company: *
   
Store Number:
   
Address: *
   
City: *
   
State: *
   
ZIP: *
   
Email:
   
Area Code: *
   
Phone: *
   
Equipment Type: *
Blood Pressure Computer
Video Scale
   
Blood Pressure Computer and Video Scale Trouble Symptoms: *
  Reading All Zeros
Cuff Won't Release
Cuff Won't Inflate
Readings Innacurate
LEDs Dim or Not Lit
No Electrical Activity
Coin Jam
Monitor Blank or Dim
Picture Shrunk
Other (describe)
 
Other Symptoms:
   
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