Form 3010
AMADEUS RMA# Request/Complaint/Case# Form Distributor
Owner: S & A Version: 17.01.2008
RMA# Request/Complaint/Case# Form
AMADEUS Support and Service
>
RMA Request
Please report your problem with the AMADEUS Microkeratome exactly according to
this procedure (PDF)
Fields marked with
*
are mandatory
Distributor
Name:
*
Contact Person:
*
Address:
*
City/ZIP:
*
Country:
*
Phone/Fax:
*
E-Mail:
*
Confirm E-Mail:
*
End consumer
Name:
Contact Person:
Address:
City/ZIP:
Country:
Phone/Fax:
E-Mail:
Material
Original Warranty
Service Agreement
Control Unit s/n:
Yes
No
Yes
No
Motor Unit s/n:
Yes
No
Yes
No
Suction Unit s/n:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Blade Holder s/n:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Surface Holder s/n:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Foot Pedal s/n:
Yes
No
Yes
No
Artificial Chamber s/n:
Yes
No
Yes
No
SurePass Blade Lot#:
Yes
No
Yes
No
SurePass Seperator Lot#:
Yes
No
Yes
No
Other
Yes
No
Yes
No
Yes
No
Yes
No
Shipment
Do you have original packing for shipping of spare parts?
Yes
No
For the return of your equipment, if not under warranty, please indicate your carrier for direct charge to your account:
*
UPS
DHL
TNT
FedEx
Fright forwarder
Other
Account number and name if not indicated before:
*
Notification type
Is this an
Case/RMA# Request and/or a
Complaint and/or
an Adverse Event ?
Has a patient been injured or was there a risk of injury?
Yes
No
If yes, have the Regulatory Authorities been notified?
Yes
No
Attach files
Problem description
(Please describe your problem as exactly as possible)
*
enter problem description here
Ziemer Ophthalmics will contact you by phone or e-mail and will either:
provide recommendations that will help you solve the problem, or
ask you to return your product for inspection and / or repair. In this case, you will receive a Return Authorization Number (RMA#) and instructions for how to ship the unit.
Do not send any AMADEUS unit or accessories back to us without an RMA number
