SPBS, Inc.

Service Request

Use the form below if you would like to request the services of SPBS

Type of Service:

Contract Quote for Electrical Safety, PM, Performance Testing New or Refurbished Equipment Full Service Contract Other

General Information

PO #:

Name: *

Address: *

City: *

State: *

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code: *

Contact: *

Email Address: *

Phone #: *

Fax #:

Bill To: *

Taxable? : *

Yes No

Program Information

General Biomedical Inspection Freq.: *

Annual Semi-Annual Other

Annual Infusion and PCA pump Full Performance Testing? *

Yes No

Semi-Annual Respiratory Ventilators Full Performance Testing? *

Yes No

Annual Electrical Bed Electrical Safety Testing? *

Yes No

Annual Electrical Outlet Testing: *

Patient Care Areas Only All Areas No

Annual Medical Gas Testing? *

Yes No

Inventory Available? *

Yes No

Equipment Information

Device or System: *

Manufacturer Desired:

Model Desired:

New or Refurbished? *

New Refurbished Either

Are funds allocated for this device? *

Yes No

How soon do you need the device/system? *

Desired price range: *

Accessories or peripherals desired:

Equipment Information

Device: *

Manufacturer: *

Model: *

Accessories or peripherals to be included:

PM's per year desired:

Type of contract desired:

Parts, Labor and PM Labor Only Parts Only PM Only

Comments: