Appendix A: Service Request Form - ResMed VPAP III, VPAP III ST, VPAP III ST-A Service Manual

Appendix A: Service request form

ResMed Service Request Form
Distributor details
Reported by
Company name
Problem details
Product details
Product code
Product name
Serial/Lot number
Problem description
Effect on user
Date problem occurred
Date of purchase
Or
If the purchase date is unknown, please indicate below the time the product was used before the problem occurred
< 3 months 3 - 6 months
When did the fault occur?
Is this device being returned to ResMed?
Service details
ResMed reference number
Mask type
Pressure settings
Hourmeter reading
6 - 12 months 1 - 2 years
Not being used During use
Yes
Distributor reference number (if applicable)
Contact details (Email or phone)
Equipment owner
Under warranty?
Humidifier?
SmartStart?
2 - 5 years
Start up
No
Appendix A: Service request form
No
Yes
No
Yes
Yes
No
> 5 years
Unknown
Today's date
AUF 19019-01/3
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