To expedite your service request, please complete this form, print it out and enclose it with your instrument. If you do not have a service agreement with Olympus, we will contact you with an estimate and the completion date for your repair service.
		Are you a service agreement customer? Yes  No If you do not have a service agreement with Olympus, we will contact you with an estimate and the completion date for your repair service. Contact your Olympus sales representative to find out how a service agreement can save your facility time and money. Select service type: Endoscope  Telescope  Accessories  Electronics
		Medical equipment that comes into contact with potentially infectious material must be decontaminated (cleaned, and then disinfected or sterilized, as appropriate) before being sent to Olympus. Customers are responsible for complying with applicable federal, state and local laws and regulations regarding decontamination of medical equipment. Please verify that the accompanying medical equipment has been: cleaned [Type initials] disinfected, or sterilized prior to shipment. [Type initials in one of the boxes above]

Date shipped to Olympus: / / Return repaired unit to this department: Facility name: Street address: City: State: Zip: Model No.: Serial No.:

Name of person to contact about repair: Title: Phone: ( ) - Extension: Fax: ( ) - Email: Pg 1 of 2: Office use / / Description of problem (to help investigate, please be specific):

		For Expedited Service: Service Agreement No.: or PO No.: Name of person approving repair: Title: Approving signature: Email: Phone: ( ) - Extension: Fax: ( ) - If using a purchase order, Olympus is authorized to complete your repair up to and including the amount indicated below: Up to $500 Up to $1,000 Up to $1,500 Up to $2,500 Up to $4,000 Up to $5,000 Other pre-approved amount
	Pg 2 of 2: Office use / /