Chiropractic Office Equipment Maintenance Checklist Form
Complete this Chiropractic Office Equipment Maintenance Checklist Form to ensure all equipment in the chiropractic office is properly inspected and maintained.
Date of Inspection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff Member Name
*
First Name
Last Name
Equipment Item
*
Please Select
Treatment Table
Ultrasound Machine
Electrical Stimulation Unit
Therapy Laser
Adjusting Tools
Hydrocollator
Other
Equipment Condition
*
Good
Requires Cleaning
Needs Repair
Out of Service
Actions Taken
Cleaned
Repaired
Reported for Service
No Action Needed
Other
Additional Notes
Next Scheduled Maintenance Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Upload Photo (Optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Maintenance Completed By (Signature)
*
Submit Checklist
Submit Checklist
Should be Empty: