Dealer CPAP Traveler Form

Dealer CPAP Traveler Form
Company Name*
Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Which Repair Authority Service Center are you sending this device to?*
Estimate Approval Contact

This is the individual who will receive the confirmation of this submission and the estimate.
Estimate Approval Name*

First NameLast Name
Estimate Approval Phone*
Phone Extension
Estimate Approval E-mail*
example@example.com
Device Information
Make/Model
Manufacturer*
Select device manufactuer
Device Model*
Repair Authority cannot repair the Philips DreamStation 2. We also cannot repair Fisher & Paykel units or discontinued units such as the discontinued models such as the ResMed S8, Respironics System One 50 Series, Legacy or Remstar.
Device Model*
Serial Number*
PO Required?*

YesNo
Purchase Order #
Optional
Work Order #
Optional
Patient ID #
Optional
Description of Problem (select as many as apply)*

Will not turn onShuts downLoud/noisyLow flow/pressureHigh flow/pressureError code/messageOverheatingNot heatingOther or error code
Peripherals Included*

Power cordCarrying caseS/D cardNone
Note: For patient safety, do not include mask, tubing or other accessories. To avoid contamination, these items will be discarded.
Special instructions or comments
After clicking Submit, you will receive an email confirmation with a PDF attachment of this form. Please print and attach the completed form to your equipment before either pickup or shipping (whichever applies). If shipping, use the following addresses:

Repair Authority Headquarters/Ohio Service Center
21973 Commerce Parkway, Dock 4
Strongsville, OH 44149
Questions: dealer@repairauthority.com or 888.828.1872

Repair Authority Texas Service Center
6701 Will Rogers Blvd.
Fort Worth, TX 76140
Questions: dealer@repairauthority.com or 888.828.1872

Repair Authority Manchester Service Center
5894 Murfreesboro Highway
Manchester, TN 37355
Questions: 800.503.9692

Thank you for choosing Repair Authority!
Should be Empty:

Dealer CPAP Traveler Form

Estimate Approval Contact

Device Information