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Ticket Requester *

Country *

<div class="form-group  helpdesk_ticket_custom_field_cf_type_of_request_ts_1321351">
    <label for="helpdesk_ticket_custom_field_cf_type_of_request_ts_1321351" class=" form-label">
    	Type of Request
	  	
	  		<span class="fw-asterisk">*</span>
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>60000754196}"}'value="Accessories">
            Accessories
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000815672}"}'value="Calibration">
            Calibration
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000754197}"}'value="Documents">
            Documents
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000788656}"}'value="Learning Management System">
            Learning Management System
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000792331}"}'value="MTS Portal">
            MTS Portal
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000820090}"}'value="PIP Stickers">
            PIP Stickers
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000754198}"}'value="Smart Equipment Management (SEM)">
            Smart Equipment Management (SEM)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000754199}"}'value="Software">
            Software
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000754200}"}'value="Spare Parts (Obsolescence, Pricing)">
            Spare Parts (Obsolescence, Pricing)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000788645}"}'value="Testing Tools">
            Testing Tools
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000754201}"}'value="Training">
            Training
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000754202}"}'value="Troubleshooting / Technical Inquiry">
            Troubleshooting / Technical Inquiry
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000754203}"}'value="Other">
            Other
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_product_family113302_1321351">
    <label for="helpdesk_ticket_custom_field_cf_product_family113302_1321351" class=" form-label">
    	Product Family
	  	
	  		<span class="fw-asterisk">*</span>
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>60000754164}"}'value="Cots, Cot Fasteners &amp; Chairs">
            Cots, Cot Fasteners &amp; Chairs
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000754165}"}'value="HeartSine">
            HeartSine
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000754166}"}'value="LIFEPAK®">
            LIFEPAK®
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000754167}"}'value="LUCAS">
            LUCAS
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000754168}"}'value="Stretchers &amp; Beds">
            Stretchers &amp; Beds
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000754204}"}'value="Surfaces / Mattresses">
            Surfaces / Mattresses
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000754169}"}'value="Temperature Management">
            Temperature Management
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000754170}"}'value="Other">
            Other
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_device_model_ts_1321351">
    <label for="helpdesk_ticket_custom_field_cf_device_model_ts_1321351" class=" form-label">
    	Device Model
	  	
	  		<span class="fw-asterisk">*</span>
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>60000793154}"}'value="0747 - Transport Stretcher">
            0747 - Transport Stretcher
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793155}"}'value="1105 - 5th Wheel Prime Series Stretcher">
            1105 - 5th Wheel Prime Series Stretcher
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793156}"}'value="1115 - Big Wheel Prime Series Stretcher">
            1115 - Big Wheel Prime Series Stretcher
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793157}"}'value="1125 - Zoom Prime Series Stretcher">
            1125 - Zoom Prime Series Stretcher
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793158}"}'value="3002 - S3 Med-Surg Bed">
            3002 - S3 Med-Surg Bed
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793159}"}'value="3009 - ProCuity™">
            3009 - ProCuity™
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793160}"}'value="3333 - TruRize Clinical Chair">
            3333 - TruRize Clinical Chair
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793161}"}'value="5900 - MV3">
            5900 - MV3
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793162}"}'value="6100 - M1 Roll-In System Ambulance Cot">
            6100 - M1 Roll-In System Ambulance Cot
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793163}"}'value="6252 - Stair Chair">
            6252 - Stair Chair
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793164}"}'value="6254 - Evacuation Chair (Green)">
            6254 - Evacuation Chair (Green)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793165}"}'value="6300 - ST1 Series Stretcher">
            6300 - ST1 Series Stretcher
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793166}"}'value="6390 - Power-LOAD">
            6390 - Power-LOAD
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793167}"}'value="6500 - Power-PRO XT Ambulance Cot">
            6500 - Power-PRO XT Ambulance Cot
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793168}"}'value="6506 - Power-PRO XT Ambulance Cot">
            6506 - Power-PRO XT Ambulance Cot
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793169}"}'value="6507 - Power-PRO 2 Ambulance Cot">
            6507 - Power-PRO 2 Ambulance Cot
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793170}"}'value="6510 - Power-PRO IT Ambulance Cot">
            6510 - Power-PRO IT Ambulance Cot
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793171}"}'value="6516 - Power-PRO IT Ambulance Cot">
            6516 - Power-PRO IT Ambulance Cot
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793172}"}'value="6550 - Power-PRO TL Ambulance Cot">
            6550 - Power-PRO TL Ambulance Cot
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793173}"}'value="7100 - SV1 Electric Hospital Bed">
            7100 - SV1 Electric Hospital Bed
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793174}"}'value="7500 - SV2 Electric Hospital Bed">
            7500 - SV2 Electric Hospital Bed
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793175}"}'value="8001 - Altrix™ Temperature Management System">
            8001 - Altrix™ Temperature Management System
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793176}"}'value="FL27 - InTouch Critical Care Bed">
            FL27 - InTouch Critical Care Bed
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793177}"}'value="Fl28C - GOBed II Med-Surg Bed">
            Fl28C - GOBed II Med-Surg Bed
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793178}"}'value="CodeManagement Module™ - CMM">
            CodeManagement Module™ - CMM
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793179}"}'value="HeartSine">
            HeartSine
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793180}"}'value="HeartSine - Gateway">
            HeartSine - Gateway
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793181}"}'value="LIFEPAK® 15">
            LIFEPAK® 15
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793182}"}'value="LIFEPAK® 20/20e">
            LIFEPAK® 20/20e
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000815670}"}'value="LIFEPAK® 35">
            LIFEPAK® 35
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793183}"}'value="LIFEPAK® 1000">
            LIFEPAK® 1000
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793184}"}'value="LIFEPAK® CR2">
            LIFEPAK® CR2
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793185}"}'value="LIFEPAK® CR Plus / CR Express">
            LIFEPAK® CR Plus / CR Express
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793186}"}'value="LUCAS">
            LUCAS
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793187}"}'value="McGRATH">
            McGRATH
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>60000793153}"}'value="Other / Unkown">
            Other / Unkown
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_serial_numbers_ts_1321351" class=" form-label">
			Serial Number(s)
			
				<span class="fw-asterisk">*</span>
			
			
		</label>

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Description *

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