Veterinary Clinic Equipment Assessment Form
Please complete this form to assess the operational status and needs of veterinary clinic equipment.
Equipment Name/ID
*
Equipment Location
*
Please Select
Examination Room 1
Examination Room 2
Surgery Suite
Laboratory
Imaging Room
Pharmacy
Kennel Area
Other
Equipment Type
*
Please Select
Diagnostic
Surgical
Monitoring
Therapeutic
Laboratory
Imaging
Other
Condition Assessment
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Functionality Status
*
Fully Functional
Partially Functional
Not Functional
Maintenance Status
*
Up to Date
Due Soon
Overdue
Unknown
Service Urgency
*
No Action Needed
Routine Service
Urgent Service Required
Assessment Details
Rows
Present
Clean
Calibrated
Before Use
1
2
3
After Use
4
5
6
Assessor Name
*
First Name
Last Name
Additional Notes
Submit Assessment
Should be Empty: