Relocations and Closures Form

Are you undergoing a clinic Relocation or Closure?*

For on-site relocations, please provide contractor information (Name, Phone Number and e-mail):

Are Night/Weekend Hours Required for this job?

Please indicate which floor of the facility where the equipment is located

Please provide the destination address. If there are multiple, you can copy and paste them here (or add as an attachment).

Select
Caret IconCaret symbol
Select or enter value
Caret IconCaret symbol

If 'Yes' please attach an example.

Select or enter value
Caret IconCaret symbol

If 'Yes' please ensure you work with a general contractor to have this work completed

Select or enter value
Caret IconCaret symbol
Select
Caret IconCaret symbol

Is the staff aware of closure or relocation?

Select
Caret IconCaret symbol

Please provide us any additional information that will help us serve you

Please upload a complete listing of all equipment with all relevant redistribution details, including destination address information in spreadsheet format.

Drag and drop files here or