EmailMeForm
ExamOne EKG Machine and Furniture Request Form
Use this form to request new equipment and/or office furniture.
NOTE: Use "Tab" to move between fields.
OFFICE INFORMATION
Please provide office number and branch manager name if in an ExamOne office. Otherwise skip to Return Information.
Office Number
Branch Manager Name
First
Last
Branch Manager Email
If the item(s) are for someone other than the Branch Manager please provide their name
First
Last
New Computer/Monitor/Headset Requests:
For new equipment requests please email the field support team, DGX LEN ExamOne Field Support.
Furniture Request
Please enter a quantity for any items being requested.
Quantity
EKG Machine
Task Chair (for Desk)
Desk
Lobby Chair
Lobby Table
Side Chair (Branch Manager Visitor Chair)
Phlebotomy Chair
Rolling Stool Exam Room
Exam Table Exam Room
EKG Cart Exam Room
Examiner Desk Exam Room
Medical Cart Exam Room
Alternate Shipping Address
Please fill in this field if the equipment/furniture is to be shipped somewhere, or to someone, other than the Branch Manager and Office address we have on file.
Alternate Address:
SOM's Approval email
*
Please upload SOM's approval email
