Device Installation Report (Service)

Customer Info.

Name Name of Hospital or Clinic Department

Address
Outpatient
Total Beds Hospital type: Public Private
number per year
Product Decive Model Serial number
Date of
Contact Person Tele / Email
Installation
Installation of Product Completed Yes No Remark
Check list
User Training of Product Completed Yes No Remark

Signature of technician:

Customer comments

Signature of User : Date:

Signature of Distributor : Date: