Bill to:

Notes:

Contact:

Email:

Please provide catalog numbers for all instruments if possible.Qty. Problem/Description (Technician Use Only)Catalog #

All repairs pre-approved

Please quote all repairs (this will affect the turnaround time)

PO#:

Phone #:

Fax #:

Ship to: (if different than bill to address)

Ship instruments securely to: Ambler Instrument Repair223 Pickle Simon Rd. #200

Winder, GA 30680

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

Surgical Instrument Repair Form*Do not use this form for Phaco / Cryo handpieces or Diamond knives*

Please choose returnshipment option:

Please choose:

FedEx Ground FedEx 2 Day FedEx Priority Overnight

SP 50-01-F7