Annual Preventative Maintenance Detailed Report
Customer Information
Company / Practice Name
Address
ONSITE
Contact Name
Contact Phone
Contact Email
Reference
Order / Contract #
Work Order (WO) #
Zoho #
Date & Time
Ophthalmic Field Service Technician
Select Equipment For Annual PM Inspection
Examination Chair
Instrument Stand
Slit Lamp
Applanation Tonometer
Non-Contact Tonometer (NCT)
Automated Perimeter / Visual Field
Manual Phoropter
Digital Phoropter
AutoRefractor / Keratometer
Keratometer (Manual)
Manual Lensometer
Digital Lensometer
Hand Held Scopes
Acuity Chart / Projector
Binocular Indirect (BIO)
Trial Frame
Trial Lens Set
Indirect Ophthalmoscope
Examination Chair
+ Add Another Chair
Room:
Manufacturer
Essilor
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Elevation Up operation verified
Elevation Down operation verified
Recline mechanism smooth
Incline return smooth
Rotates and Locks properly
Foot Switch fully operational
Foot Rest inspected and secure
Arm Rests secure & pivot smoothly
Head Rest locking and clamp functioning
Cleaned and wiped down
Checked Upholstery for wear / tears
Lubricated pivot joints & hydraulic/glide shafts
Wheelchair accessibility functions verified
PM Status
Passed PM
Needs Service
Instrument Stand
+ Add Another Stand
Room:
Manufacturer
Essilor
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Overhead Light & dimmer operational
Slit Lamp Safety Switch operational
Lower Refractor Arm w/Quick Release adjusted
Collar for Safety verified & tight
Cable and Pulley System inspected
Cleaned exterior and tracks
Lubricated counter-balance and arms
Wheelchair access clearance verified
PM Status
Passed PM
Needs Service
Slit Lamp
+ Add Another Slit Lamp
Room:
Manufacturer
Essilor
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Light Intensity & bulb quality verified
Power Switch & rheostat verified
Check all mechanical functions & joystick
Cleaned chassis and glide tracks
Lubricated mechanical slide guides
Cleaned Optics (eyepieces, drum, objective)
Level Table Mount & lock verified
PM Status
Passed PM
Needs Service
Applanation Tonometer
+ Add Another Tonometer
Room:
Manufacturer
Essilor
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Calibration weight verification pass (0, 2, 6 g)
Mechanical analog functions verified
Lubricated pivot mechanism
Cleaned exterior and prism holder
PM Status
Passed PM
Needs Service
Non-Contact Tonometer (NCT)
+ Add Another NCT
Room:
Manufacturer
Essilor
Reichert (7CR / 7 / PT100)
Topcon (CT-800 / CT-80 / CT-1P)
Nidek (NT-530 / NT-510)
Canon (TX-20 / TX-20P)
Keeler (Pulsair)
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Air puff nozzle & pneumatic orifice inspected and cleaned of lint/dust
Cleaned alignment window, objective sensors & fixation target optics
Air pump pressure chamber & transducer pulse verified
3D Auto-alignment, auto-fire & positioning sensors verified
Motorized chinrest travel, safety stop & forehead rest operational
Calibration verified against certified rubber test eye / reference chamber
Internal thermal printer mechanism cleaned & test print passed
RS-232 / USB / LAN data communication verified
PM Status
Passed PM
Needs Service
Automated Perimeter / Visual Field
+ Add Another Perimeter
Room:
Manufacturer
Essilor
Optopol (PTS)
Zeiss (HFA)
Haag-Streit (Octopus)
Oculus (Easyfield / Twinfield)
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Perimeter bowl interior cleaned with lint-free cloth (no dust / marks)
Bowl background luminance calibrated (photometer verify standard 31.5 asb / 10 cd/m²)
Stimulus projection shutter, lamp intensity & target presentation verified
Fixation tracking camera & pupil alignment gaze monitoring calibrated
Patient response button / clicker trigger & cable continuity tested
Motorized chinrest / forehead rest mechanism & vertical drive lubricated
Software database integrity, normative data & baseline diagnostic test passed
DICOM / EMR network export & report printer validated
PM Status
Passed PM
Needs Service
Manual Phoropter
+ Add Another Manual Phoropter
Room:
Manufacturer
Essilor
Reichert
Marco
Topcon
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Mechanical leveling bubble verified & adjusted
Sphere & Cylinder dial battery gear mesh smooth (no slipping / binding)
Jackson Cross-Cylinder rotation, flip tension & alignment detents smooth
Rotary prism zero-point alignment & auxiliary lens turrets indexed
Interpupillary Distance (IPD) mechanism & convergence levers verified
Corneal vertex alignment scale & viewing mirrors clean
Aperture lenses cleaned and degreased
Near point reading rod and card holder inspected
PM Status
Passed PM
Needs Service
Digital Phoropter (Automated Refractor)
+ Add Another Digital Phoropter
Room:
Manufacturer
Essilor
Topcon
Nidek
Reichert
Model
Optical Head S/N
Console / Tablet S/N
Software / Firmware Version
Condition
Good
Fair
Poor
Inspection Checklist
Optical head stepper motor self-test, homing & zero-point initialization pass
Lens turret positioning repeatability and optical sensor alignment verified
Motorized IPD adjustment & convergence positioning calibrated
Touch controller / tablet wireless communication & dial responsiveness tested
Acuity chart screen target synchronization & polarization verified
Power supply unit (PSU) rail voltages & cabling strain-relief inspected
EMR / Auto-Refractor / Lensometer interface communication verified
Optical apertures cleaned and forehead/face shield sanitized
PM Status
Passed PM
Needs Service
AutoRefractor / Keratometer
+ Add Another AutoRefractor
Room:
Manufacturer
Essilor
Topcon
Nidek
Canon
Reichert
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Cleaned objective window, internal mirrors & fixation target
Mire ring LED projection & alignment calibrated
Rotary prism / wavefront sensor zeroed and tested
3D Auto-tracking / joystick alignment motors operational
Motorized chinrest movement, belt & limit switches verified
Internal thermal printer head cleaned & test print passed
Calibration checked on certified Model Eye standard (Sph, Cyl, K-reading)
EMR / data output communication verified
PM Status
Passed PM
Needs Service
Keratometer (Manual)
+ Add Another Keratometer
Room:
Manufacturer
Essilor
Marco
Topcon
Reichert
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Mechanical analog functions verified
Electrical (wires, connections, power)
Light Intensity & bulb quality
Power Switch verified
Checked all optical dials and functions
Cleaned exterior and stage
Lubricated focus glide mechanism
Cleaned mire optics and eyepieces
Check Calibration with steel ball standards
PM Status
Passed PM
Needs Service
Manual Lensometer
+ Add Another Manual Lensometer
Room:
Manufacturer
Essilor
Marco
Topcon
Reichert
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Mechanical analog functions & power wheel smooth
Axis wheel and 180° lens table alignment verified
Marking pins inked, aligned, and level
Light Intensity & reticle illumination verified
Prism compensator verified and zeroed
Cleaned eyepiece, nosepiece & target optics
Lubricated stage slide & focus mechanism
PM Status
Passed PM
Needs Service
Digital Lensometer
+ Add Another Digital Lensometer
Room:
Manufacturer
Essilor
Nidek
Topcon
Reichert
Tomey
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Cleaned Hartmann multi-point sensor grid & nosepiece aperture
Lens stop nosepiece ring inspected & microswitch contact verified
Lens table slide guide tensioned, squared to 180° & lubricated
3-dot marking pin assembly aligned, leveled & re-inked
UV / Blue light transmittance sensor cleaned & baseline response zeroed
Calibration checked against certified master test lens set (Sph/Cyl/Prism)
Progressive addition (PAL) detection algorithm & ADD test pass
Internal thermal printer cleaned & test receipt printed
RS-232 / USB / LAN / Wi-Fi data export verified
PM Status
Passed PM
Needs Service
Hand Held Scopes
+ Add Another Set
Room:
Manufacturers
Essilor
Models
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Cleaned lenses, mirrors & apertures
Mechanical analog functions verified
Light Functionality & rheostat tested
Charges Properly in desktop/wall well
PM Status
Passed PM
Needs Service
Acuity Chart / Projector
+ Add Another Acuity Chart
Room:
Manufacturer
Essilor
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Mirror (optional) aligned and cleaned
Power Switch & remote sensor responsive
Check all optotypes and masking functions
Cleaned screen / housing
Lubricated projector slides if applicable
Cleaned projection lenses
Check working distance Calibration
Cleaned Slides / test plates
PM Status
Passed PM
Needs Service
Binocular Indirect (BIO)
+ Add Another BIO
Room:
Manufacturer
Essilor
Keeler
Heine
Welch Allyn
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Electrical (wires, connections, power harness)
Check all headband adjustments & filters
Check Bulb / LED output
Cleaned headband & outer casing
Cleaned viewing Optics & mirrors
PM Status
Passed PM
Needs Service
Trial Frame
+ Add Another Trial Frame
Room:
Manufacturer
Essilor
Oculus
Richmond
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Mechanical analog functions (PD, temple, bridge dials) smooth
Lens Alignment & axis rotation verified
PM Status
Passed PM
Needs Service
Trial Lens Set
+ Add Another Trial Lens Set
Room:
Manufacturer
Essilor
Oculus
Richmond
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Set Is Complete (lenses, cylinders, prisms verified)
PM Status
Passed PM
Needs Service
Indirect Ophthalmoscope
+ Add Another Indirect
Room:
Manufacturer
Essilor
Model
S/N or Asset Tag
Condition
Good
Fair
Poor
Inspection Checklist
Optics (clean)
Mechanical (analog functions)
Electrical (wires, connections, power)
Light Intensity verified
Charging (Optional) functional
PM Status
Passed PM
Needs Service
Additional PM Notes & Recommendations
Signatures & Sign-off
Customer Approval: (Signature)
Clear Customer Signature
Customer Printed Name
Ophthalmic Field Service Technician: (Signature)
Clear Technician Signature
Technician Printed Name
Complete Annual PM Report