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Technical Support Request Form

Contact Information: Please identify yourself and tell us how we may best contact you. Please fill in your customer number if possible and/or a Return Authorization (RA) number if one has been provided by OPTI Medical Technical Support.
* = Required
Company Name *
Country *
Customer Number
Return Authorization #
Contact Name *
E-mail Address: *
Telephone
Instrument Information: Which instrument model and serial number is this ticket for? What is the installed software version?
Instrument Model *
Serial Number(s)
Software Version
Consumables Information: Which consumables were being used when the problem occurred?
Cassette Type
Cassette Lot #
Gas Bottle Lot #
Fluid Pack Lot #
OPTI Check Type
OPTI Check Lot #
CVC Material Type
CVC Material Lot #
SRC Type
SRC Lot #
Hb Calibrator Lot #
Comfort Sampler Lot #
Peristaltic Pump Manufacture Date (DOM)
Problem Description: Please use the fields below to help describe the problem.
Hardware Problem
Consumable Problem
Communication Problem
Patient Results Problem
QC Results Problem
Power Related Problem
Software Related Problem
Error Message 1
Error Message 2
Please enter a description of the problem or tell us how we can help:
Problem Description
Attach a File (error log, picture, etc. - max size 2.5 MB):


* Required

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