Prism Medical FGSH-450, Owner'S Manual, Page: 27 / 29

280490 FGSH-450 - Owner’s Manual Rev: 03/25/13 Page: 27
Service Record History
Complete this section after each service, repair inspection and/
or maintenance. Photocopy additional pages as required.
Service Type:
□ Periodic Inspection □ Monthly Inspection □ 6 Month Inspection □ Repair □ Yearly Inspection □ Other:_________
Completed By :
_________________________
_____________________________
Printed Name Signature
Company: _____________________________________________________________
Remarks & Action Taken:
Date: _______________________ Time: ________________________
Service Type:
□ Periodic Inspection □ Monthly Inspection □ 6 Month Inspection □ Repair □ Yearly Inspection □ Other:_________
Completed By :
_________________________
_____________________________
Printed Name Signature
Company: _____________________________________________________________
Remarks & Action Taken:
Date: _______________________ Time: ________________________
Service Type:
□ Periodic Inspection □ Monthly Inspection □ 6 Month Inspection □ Repair □ Yearly Inspection □ Other:_________
Completed By :
_________________________
_____________________________
Printed Name Signature
Company: _____________________________________________________________
Remarks & Action Taken:
Date: _______________________ Time: ________________________
Service Type:
□ Periodic Inspection □ Monthly Inspection □ 6 Month Inspection □ Repair □ Yearly Inspection □ Other:_________
Completed By :
_________________________
_____________________________
Printed Name Signature
Company: _____________________________________________________________
Remarks & Action Taken:
Date: _______________________ Time: ________________________
Service Type:
□ Periodic Inspection □ Monthly Inspection □ 6 Month Inspection □ Repair □ Yearly Inspection □ Other:_________
Completed By :
_________________________
_____________________________
Printed Name Signature
Company: _____________________________________________________________
Remarks & Action Taken:
Date: _______________________ Time: ________________________
Service Type:
□ Periodic Inspection □ Monthly Inspection □ 6 Month Inspection □ Repair □ Yearly Inspection □ Other:_________
Completed By :
_________________________
_____________________________
Printed Name Signature
Company: _____________________________________________________________
Remarks & Action Taken:
Date: _______________________ Time: ________________________