Ultrasound Exam Table Maintenance Request Form
Submit maintenance needs for ultrasound exam tables to ensure prompt service and minimal downtime.
Date of Request
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department or Room Location
*
Ultrasound Table Model/Type
*
Table Serial Number or Asset ID
*
Type of Issue
*
Please Select
Mechanical (height, tilt, movement)
Electrical (power, controls, outlets)
Surface Damage (padding, cover, tears)
Hydraulic/Pneumatic
Other
Detailed Description of the Issue
*
Urgency Level
*
Critical - Table unusable
High - Major impact to workflow
Moderate - Some impact
Low - Minor issue
Is the table currently in use with patients?
*
Yes
No
Previous Service or Repairs Noted?
Yes
No
Unknown
Staff Contact Name and Phone/Extension
*
Submit Maintenance Request
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