Repair Request

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* Required information.

Repair Information Form

Send Equipment to:
Riley's Medical Repair Center 3129 Demaret Dr. Titusville, Fl. 32780.

Please Call or Fax prior to actually sending equipment so that we know when to expect it.

Call 321 268-3342 | Fax 321 385-1942

Contact Name
Organization *
Email Address *
Contact Phone #1 *
Contact Phone #2
Street Address
City
State
Zipcode

Type of Equipment - #1
Serial Number
Purchase Date
Describe the Problem You Are Seeing

Type of Equipment - #2
Serial Number
Purchase Date
Describe the Problem You Are Seeing
Shipping Method (Fedex 2nd day? UPS overnight? USPS 1st Class?

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