Support Request Form

1
unique id
Press
Enter
2
Company Name* This field is required
Press
Enter
3
E-mail* This field is required
example@example.com
Press
Enter
4
Phone Number* This field is required+233xxxxxx
Press
Enter
5
City / Town* This field is required
Press
Enter
6
I am having a problem with this equipment* This field is requiredEquipment Brand Name
Press
Enter
7
Type of equipment* This field is required
MRI
Xray
Ultrasound
Monitors/ICU
CR/DR
Other
Press
Enter
8
Which type?* This field is required
Press
Enter
9
Equipment Model Name* This field is required
Press
Enter
10
Serial NumberPut the equipment SERIAL NUMBER
Press
Enter
11
Error Code Put the equipment ERROR CODE
Press
Enter
12
Error Message
Press
Enter
13
Additional InformationDescribe Your Problem
Small
Normal
Large
Huge
Ok
Ok
Press
Enter
14
How would you like to be contacted?
By phone
By e-mail
Press
Enter
15
Type a question
Press
Enter
Should be Empty: