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Medical Questionnaire

Please fill out the Medical Questionnaire form below

* Required Field

Contact one of our sales representatives today
to inquire about a quote from Cold Shot Chillers
or call us today at 1-800-473-9178

Type of Process being Cooled:

Equipment Manufacture and Model Number:

City Water Switch Over Required:	Yes	No
Air Compressor and Refrigerated Air Drier Required:	Yes	No
Coolant Flow Rate:		gpm	gph
System Pressure:		psi	bar
Required Fluid Temperature:		°F	°C
Power Requirements:	Volts		Phase	Hz
Type of Condenser:
Chiller Location:
If Outdoors Please Describe Ambient Conditions:

* Any Special Notes:

Cold Shot Chillers. Economical. Dependable.