Appendix A: Service request form
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Appendix A: Service request form
ResMed Service Request Form
Distributor details
Reported by
Equipment owner
Company name
Contact details (Email or phone)
Problem details
Product details
Serial/Lot number
Product name
Product code
Mask type
Hourmeter reading
Pressure settings
Under warranty?
Humidifier?
SmartStart?
Yes
Yes
Yes
No
No
No
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
1 - 2 years
6 - 12 months
> 5 years
2 - 5 years
When did the fault occur?
During use
Not being used
Unknown
Start up
Is this device being returned to ResMed?
No
Yes
Service details
ResMed reference number
Today’s date
Distributor reference number (if applicable)
AUF 19019-01/3
