Equipment Maintenance Form

Your Name *

Clinic *

Today's Date *

ALEX & YAG

ALEX - Maintenance *

	Yes	No
Tech Goggles Checked & are in Good Condition	Yes	No
Patient Goggles Checked & are in Good Condition	Yes	No
Slider Lens Checked for Pitting (hold up into light)	Yes	No
Slider Window Checked (replace if needed)	Yes	No
Laser Fiber Checked	Yes	No
Calport Clean	Yes	No
Water Level Checked	Yes	No
Distance Gauges Cleaned & PHOTO taken	Yes	No
Calibration Done (18mm 20J) & PHOTO taken	Yes	No
Filter (Lt side bottom) PHOTO taken & Cleaned	Yes	No

YAG - Maintenance *

	Yes	No
Tech Goggles Checked & are in Good Condition	Yes	No
Patient Goggles Checked & are in Good Condition	Yes	No
Slider Lens Checked for Pitting (hold up into light)	Yes	No
Slider Window Checked (replace if needed)	Yes	No
Laser Fiber Checked	Yes	No
Calport Clean	Yes	No
Water Level Checked	Yes	No
Distance Gauges Cleaned & PHOTO taken	Yes	No
Calibration Done (15mm 44J) & PHOTO taken	Yes	No
Filter (Lt side bottom) PHOTO taken & Cleaned	Yes	No

LVM SCREEN DETAILS
ALEX = HV>1800 BAD, HD>68 BAD, CP must be less than HD, TX<70BAD
YAG = HV >1100 BAD, HD>98 BAD, CP must be less than HD, TX<70BAD *

	Total Pulses	HV	HD	CP	TX
ALEX	Total Pulses	HV	HD	CP	TX
YAG	Total Pulses	HV	HD	CP	TX

ALEX PHOTOS

ALEX - Photo of DG Windows *

ALEX Picture of Filters *

ALEX LVM Screen (calibrate at 18mm 20j) *

YAG PHOTOS

YAG - Photo of DG Windows *

YAG Picture of Filters *

YAG LVM Screen (calibrate at 15mm 44j) *

Mesopen & Ultrasonic

Ultrasonic - Electrical Cord Straightened *

Yes

Photo of US Machine *

Photo of Mesopen Machine *

Supply Room

Photo of Shelf #1 *

Photo of Shelf #2 *

CRYO Canisters

On Machines *

Empty Cryo *

Full Cryo *

ALEX & YAG WINDOWS

	Total NEW Left in Inventory
ALEX Windows	Total NEW Left in Inventory
YAG Windows	Total NEW Left in Inventory

Notes (if any)

Zeltiq Cards (If Relevant)

Large

Small

Flat