Medical Device Worksheet Company Name Contact Name * First Name Last Name Email * Phone (###) ### #### Model/manufacturer of your device * Serial Number * Accessories/attachments (please list all) When was the last time this device was used? Pulse counts (send picture of machine showing this), if applicable? Is this device in working order? If not, what are the fault codes? The device is (check one) * Owned Leased If leased, do you have permission to sell? What price range are you expecting? Would you consider trading this device? Thank you!
