Bill to:

Alcon®*Alcon®*AMO®*AMO®*Storz®*

Centurion® / Ozil®

Turbosonics® / Ultrasonic®

Ellips FX®

Sovereign® / Whitestar®

Stellaris® AttuneTM / MillenniumTM

$1350.00

$995.00

$1350.00

$995.00

$995.00

Please select Warranty 6 Month Warranty 12 Month Warranty$1650.00

$1295.00

$1650.00

$1295.00

$1295.00

Contact:

Email:

Phone #:

Fax #:

Ship to: (if different than bill to address)

Ship handpieces securely to: Ambler Phaco HP Repair539 Pasadena Ave. SouthSt. Petersburg, FL 33707

Phaco Handpiece Repair Form

amblersurgical.com P: 1-888-407-0006 F: 610-280-7909

Manufacturer Serial #Model Problem/DescriptionPlease provide information if available.

Notes:

Please choose returnshipment option: FedEx Ground FedEx 2 Day FedEx Priority Overnight

PO#: Signature Required:

Repair pre-approval: Ambler Surgical is authorized to proceed with the complete refurbishment of the phacohandpiece(s) listed below at the pricing and warranty option selected above.

*The above referenced companies are registered trademarks of the respective owners. Ambler Surgical has no affiliation whatsoever with the companies,nor do we distribute their products. Prices subject to change without notice.

SP 50-01-F5