Ecolab Healthcare - DAZO Replacement Device (iPod / iPad)

Contact Information

Date * +

Your Email Address *

Account Number *

Customer Name *

Contact Phone Number

Contact Email Address

Shipping Method *

SHIPPING DETAILS - STANDARD

3-5 business days

3:00 PM CST cut-off time

SHIPPING DETAILS - OVERNIGHT

Next day delivery

2:00 PM CST cut-off time

Shipping Country *

Shipping to *

Customer

Account Executive's Address

Account Executive Shipping Address

AE Name *

AE Phone Number

Address Line 1 *

Address Line 2

City *

State/Province *

Zip/Postal Code *

AE Cost Center * 🛈

Customer Shipping Information

Contact Name *

Department

PO #

Address Line 1 *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Cost Center * 🛈

Order Type

Why are you ordering a new device? *

Additional Device

Replacement Device

Order Details - Additional Devices

For additional devices, you will need to gather approval from Marketing (IP - Hank.Carbone@ecolab.com, OR - Beth.Hohl@ecolab.com) to add to a device and determine if a charge for the device needs to billed to the customer

Reason for Additional Device *

New Facility / Rooms Added

Other Other

What was the Original Device the Customer had on-site? *

Item #1 *

Quantity *

Order an additional type of device?

Yes

No

Item #2

Quantity

Order Details - Replacement Devices

For replacement devices, provide the following details:

Reason for Replacement *

Device Broken (battery dead, screen broken, etc.)

Customer Cannot Recall Device Login Info

Other Other

Steps Taken to Avoid Replacement *

Worked with Customer to Troubleshoot

Reached out to Encompass Support for Additional Support

Other Other

What was the Original Device the Customer had on-site? *

Item #1 *

Quantity - Item #1 *

Replace an additional device

Yes

No

Item #2

Quantity - Item #2

Usernames - EnCompass Billing

Will there be an additional charges associated with this order? *

Yes

No

Billing Options - #1 *

Quantity - Billing Option #1 *

Add Invoice Item? *

Yes

No

Billing Options - #2 *

Quantity - Billing Option #2 *

Add Invoice Item? *

Yes

No

Billing Options - #3 *

Quantity - Billing Option #3 *

Usernames - EnCompass Collection App

You need to provide the Usernames from the Encompass Collection App to complete the replacement process

Don't know your customer's Encompass Collection App Username?

Follow the below link

Customer Look-up & Reporting

Insert the appropriate Account Number in the "Enter Account Number" field

NOTE - If your Account is an IP Account, you will need to add a leading "0" (Ex - 020681054)

Locate the Mobile App Users section

Add the users to be added to the device(s) you are replacing

View Location of Mobile Users on Customer Look-up & Reporting Tool

View image

EnCompass Application Details (password is the same as Username)

	Username
1	Username
2	Username
3	Username
4	Username
5	Username

Notes

Additional Instructions/Comments