In-House Auto Refractor / Keratometer Repair Report
Customer Information
Company / Practice Name
Address
Contact Name
Contact Phone
Contact Email
Shop Service Reference
RMA / Repair Order #
Sales Order / Case #
Zoho #
Date Received / Logged
Ophthalmic Field Service Technician
Unit Identification & Incoming State
Manufacturer
Model
Serial Number (S/N)
Firmware / Software Version
Incoming Physical Condition
Good
Fair
Heavily Worn / Damaged
Customer Reported Problem / Symptoms
Diagnostic Findings & Service Operations
Technical Root Cause & Findings
Completed Service & Reconditioning Steps
Chassis covers removed, optical chamber de-dusted, and internal cleaning completed
Objective window, internal splitting mirrors, sensor lenses, and fixation target optics cleaned
Mire ring LED projection & reflection system inspected, aligned, and calibrated
Rotary prism / wavefront sensor drive mechanism calibrated and centered
3D Auto-tracking / joystick alignment sensors and motor drives verified
Motorized chinrest drive belt, gears, and limit switches serviced
Main SMPS power supply voltage rails, capacitors, and cable harnesses verified
Internal thermal printer head cleaned, feed roller adjusted, and test receipt printed
Refraction & Keratometry calibration validated against certified Model Eye standards (Sphere, Cylinder, Axis, R1/R2)
Firmware verified / re-flashed to manufacturer standard release
Serial RS-232 / LAN / Wi-Fi EMR communication test passed
Detailed Repair & Rebuild Notes
Parts & Components Replaced
Part / SKU #
Description
Qty
Action
✕
+ Add Replaced Part
Final Calibration Metrics & Quality Assurance
Model Eye 0.00 D Test
Model Eye -5.00 D Test
Model Eye +5.00 D Test
Model Eye Keratometry Test (R1 / R2)
Measurement repeatability & accuracy test pass (10 consecutive shots within tolerance)
Touchscreen display and button controls fully responsive
Electrical safety and ground continuity bench test pass
Final exterior wipe down, dust cover placed, and packed for return shipping
Overall Service Status
Repair Completed — QA Passed
Pending Parts
BER (Beyond Repair)
Signatures & Service Approval
Supervisor: (Signature)
Clear Supervisor Signature
Supervisor Printed Name
Ophthalmic Field Service Technician: (Signature)
Clear Technician Signature
Technician Printed Name
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