In-Field Auto Refractor / Keratometer Repair Report
Customer Information (Service Location)
Company / Practice Name
Address (Onsite Geolocation)
ONSITE
Contact Name
Contact Phone
Contact Email
Field Service Reference
Work Order (WO) #
Sales Order # / Case #
Zoho #
Date & Time Onsite
Ophthalmic Field Service Technician
Unit Identification & Lane Environment
Manufacturer
Model
Serial Number (S/N)
Exam Lane / Room #
Table / Mounting Type
Single Motorized Instrument Table
Dual Sliding Instrument Table
Wheelchair Accessible Table
Fixed Desk / Countertop
Firmware / Software Version
Overall Physical Condition
Good
Fair
Poor / Damaged
Customer Reported Problem / Symptoms in Practice
On-Site Diagnostic Findings & Repair Actions
Technician Findings & Root Cause Analysis
Completed Field Service & Reconditioning Actions
Objective window, internal splitting mirror, and sensor path cleaned
Mire ring projection LEDs, reflection sensor, and optical alignment calibrated
Rotary prism / wavefront sensor drive mechanism calibrated and zeroed
3D Auto-tracking / joystick alignment motors and sensors serviced
Motorized chinrest drive mechanism, belt tension, and limit switches adjusted
Power supply, table power harness, and interconnect cabling verified
Internal thermal printer head cleaned, paper path cleared, and test print passed
Refraction & Keratometry calibrated on-site against certified Model Eye standard
EMR / EHR data transfer (RS-232 / LAN / Wi-Fi) verified to practice software
Final Site & Customer Close-out Actions
Equipment wiped down, chinrest/forehead rest sanitized
Defective parts, shipping boxes, and packing material removed from customer lane
Exam table area cleaned and vacuumed
Consulted with staff / technician regarding proper lens cleaning and maintenance
Unit covered with protective dust cover upon service completion
Detailed Repair, Adjustment & Calibration Notes
On-Site Model Eye Calibration Verification
Model Eye 0.00 D Test
Model Eye -5.00 D Test
Model Eye +5.00 D Test
Keratometry (R1 / R2) Test
Parts & Consumables Replaced On-Site
Part / SKU #
Description
Qty
Action
✕
+ Add Replaced Part
Operational Verification & Final Status
Installed, Calibrated & 100% Functional for Patient Care
Yes — Fully Operational
No — Pending Follow-up
On-Site Signatures & Sign-off
Customer Approval: (Signature)
Clear Customer Signature
Customer Printed Name
Ophthalmic Field Service Technician: (Signature)
Clear Technician Signature
Technician Printed Name
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