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Medical Equipment Work Order Card

Date :- ……………………………
Ward name :-………………………………………………………………. Room No, …………………………………………………….
Name of item:-……………………………………………………….inventory No, ………………………………………………………
Model:-…………………………………….serial No, …………………………………………………………………………………………….
Failure of symptoms :-……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………….

Risk level :- High medium low

Name of person request: - ………………………………………………………….. Sign ………………………………………………


Engineer/Technician receive order
Name: - …………………………………………………………… Sign ……………………………. Date ……………………………………..
Work order No,…………………………………………………………………………………………………………………………………………

Medical Equipment Work Order Card


Date :- ……………………………
Ward name :-………………………………………………………………. Room No, …………………………………………………….
Name of item:-……………………………………………………….inventory No, ………………………………………………………
Model:-…………………………………….serial No, …………………………………………………………………………………………….
Failure of symptoms :-……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………….

Risk level :- High medium low

Name of person request: - ………………………………………………………….. Sign ………………………………………………


Engineer/Technician receive order
Name: - …………………………………………………………… Sign ……………………………. Date ……………………………………..
Work order No,…………………………………………………………………………………………………………………………………………

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