HEALTH FACILITY MEDICAL DEVICE TECHNICAL SUPPORT REQUEST FORM

We would love to hear from you! Please fill out this form and we will get in touch with you shortly.

Facility Name*
Contact Person*
Your Address*
City Zone / Region
Your Phone*
Your Email Address*
Equipment name*
Equipment manufacturer*
Agent in Ethiopia*
Equipment model
Installation Support
- Installation
- Technical Training
- User Training
Maintenance Support*
- Under Warranty
- After Warranty
Installation Date
DD slash MM slash YYYY
Device Failure Remark

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