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QULF c.7J1EDICAL CO CLTD.
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GMC-F-079
PrO'lliaing state oftlie art meaica[teclinoCogy Rev: 1.0
Since 1983. SERVICE REPORT Eff. Date: 15-02-2021
No. 2025 .
Date: ........ , ......... , ...............
Hospital Name DSH - Sahafa
Owz Dez
Hospital Department ..............
Operation Company Riyadh
City ................................................................ .
Ticket ID .... ................................................. Working Hours .................. ....... Travel Hours ......
D Repair D Installation D PPM D Delivery D Recall D Service Request D .......................
I Medical Device InformationI
Model No. Description Serial No. Manufacturer
WM-NP3 ENT Tower 22331128 Olympus
CoverageD Warranty D Service Contract D Purchase Order Invoice# ................................... Foe □
IComplaint received I D Fully Down D Partially down D No Complaint □ ..................... .........
{E. D Defective Parts D Electrical Malfunction D Mechanical Malfunction � D Parts / Accessories replacement D Calibration
□ □
C:
a,
5 D Software Issue Accessories Issue Calibration needed ! D Parts / Accessories fixed D Software Update
I!:! D Leakage D . ............ .................... D ................................ � D Overseas Repair/ replacement D .................. ...............
.2
� Remarks ......................................................... ......................................................... o Remarks ..................................... ............................................................
D Inspection Completed D Inspection Completed 0 PPM Completed D Delivery Completed
"C D Repair in progress Warranty ( Years ) .......................... . Next PPM Due Date ..... I.... I DN # ................................ .
e
a,
INV#··············•···········•·····
.ga, D Repair Completed Customer PO Contract Invoice# ..........................
0.. PPM has been done D Recall Completed D lncompleted
D Field Notice Signed D Site is Not Ready
D Parts Replaced / Fixed
Checklist attached
······································••···· ············································································· �------------'
D Device connected patient
IService final StatusI D Working in good condition D Work in progress-Don't use the device D Device Replaced with SN# •· •··············
D Partially working D Returned to supplier/G C for repair
D Under observation D Demo provided SN# ..................... ............................................................ ...........................
Remarks ....................... ................................................ ................................................................................................. ................................................
Spare Parts I D Parts installed D Parts to be requested D Parts to be Quoted D No Spare Parts used
# Part No. Description Qty. # Part No. Description Qty.
1 4
2 5
3 6
Customer Name.................................................................................................
Eng . Fahad . Customer Name .................................. .................................................................
l ________,I
Position...............................................
Engineer Department.........................................
Biomedical Position.............. ............................... . Department ..............
Date ......... ...... I ·················
10 I .. 11 2025 Date ......... I ........ I ...................
Signature ._
I _______,
Signature
Mobile Mobile
_
Customer Remarks ..... ................................................................................................... .............................. ........................................................................ ....................
Service Engineer Faisal Signature Date .........
10 I .......
11 /. ...............
2025 .
SAPID 11796
Team eader Initials H.D
........................................... ............ .