Parkell Repair Service Form – Fill Out and Use This PDF

Parkell Repair Service Form

Send repairs to: Parkell, Att: Repair Department 300A Executive Drive, Edgewood, NY 11717

Phone: 631-249-1134 • Fax: 631-249-1242 • E-mail: Repairs@Parkell.com

**Please fill out this form and include a copy of it with your repair.

Name: ________________________________________________________________________________

Address: ______________________________________________________________________________

City: ______________________________________________ State: __________ Zip: _______________

Person in your office we can contact about this repair: __________________________________________

Phone: ____________________________________ Fax #: ______________________________________

E-mail: ________________________________________________________________________________

Preferred method of contact:

 Phone

 E-mail

 Fax

Office hours: ___________________________________________________________________________

Device: ________________________________________________________________________________

Serial #: _______________________________________________ Date of Purchase:__________________

Problem with Device:______________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

An $80.00 bench fee will be charged for most non-warranty repairs; if you go ahead with the repair the $80.00 bench fee with be waived.

Waive bench fee and repair unit?

 Yes

 No

I pre-authorize Parkell to repair my device if the repair is under $_______________. If the repair is over the

authorized amount we will contact you first before proceeding with the repair.

___________________________________________________________________

SignatureDate

Parkell Use Only:

Date Received: _____________ By: _____________________________________________________________

Accessories Received: _________________________________________________________________________

___________________________________________________________________________________________

Bench Test Fee: _____________ Approved By: ___________________________ Date Approved: __________

Repair Estimate: _____________ Approved By: ___________________________ Date Approved: ___________