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Amc/Cmc/Repairs/Others Request Form - Biomedical Date

The document is a request form for AMC/CMC/repairs or other services for biomedical equipment. It collects information about the hospital, department, equipment details, service history, present cost estimates, required service, vendor details, quotations, alternative options, remarks, and enclosures. The form is signed by the center head and unit biomedical engineer and includes fields for corporate approval status, group head signature, and approving authority signature.

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PAPPU RANJITH KUMAR
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1K views1 page

Amc/Cmc/Repairs/Others Request Form - Biomedical Date

The document is a request form for AMC/CMC/repairs or other services for biomedical equipment. It collects information about the hospital, department, equipment details, service history, present cost estimates, required service, vendor details, quotations, alternative options, remarks, and enclosures. The form is signed by the center head and unit biomedical engineer and includes fields for corporate approval status, group head signature, and approving authority signature.

Uploaded by

PAPPU RANJITH KUMAR
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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AMC/CMC/REPAIRS/OTHERS REQUEST FORM - BIOMEDICAL DATE:

• Name of the Hospital:……………………………………………………Location:………………………………….


• Department & Requested By: …………………………………………………………………………………………
• Equipment Name & Details: …………………………………………………………………………………………….
• Acquisition / Asset Value: ……………………………… Installation Date: ……………………………………
• Age of the Equipment: ……………………………………Warranty Details: …………………………………..
• Last Year AMC/CMC/Repair Details with Cost: …………………………………………………………………
• Present AMC/CMC/Repair Cost: ………………………………………………………………………………………
• Type of Service required : AMC/CMC/REPAIR /CALIBRATION/INSPECTION/UPGRADATION
• Vendor details: ………………………………………………………………………………………………………………..
• Quotations: ……………………………………………………………………………………………………………………..
• Any other alternative options: …………………………………………………………………………………………
• Remarks / Addl. Info: ……………………………………………………………………………………………………….
• Enclosures: 1. Last Year AMC/CMC/Repair Copy:
2. Quotations by company:
3. Alternative Quotations:

Centre Head Sign: Unit BME Sign:


Below For Corporate Use Only
Approval Status:
Under Negotiation Negotiated Rejected

Hold Approved PO Status

Group Head Biomedical Approving Authority:

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