Customer Service Request Form

Please complete the following form to report any customer service or product issues.

Describe Equipment Needing Service
Please find and attach serial numbers or photos of the serial number tags. Accurate serial numbers will identify equipment and speed up diagnosis and response time.
Model*
Describe 'other' that needs service
System Serial Number*
Enter N/A if unavailable. A serial number can provide us with the ability to respond quicker.
Handpiece or Component Serial Number*
Use N/A if unavailable
Date Reported*
Enter the date you first were aware of the issue.
MM slash DD slash YYYY
Who should we contact about the issue?
Contact*
First Last
Phone*
Email
Where is the equipment requiring service?
Account Name*
name of practice or business
Address
Enter the location of the equipment that is requiring service.
What is the issue?
Describe Customer's issue and your diagnosis*
Also describe any unusual condition
Images or Files Related to Repair
Only upload helpful images or videos of the problem. Images of the error message on the control screen with the image of the entire screen with the error message is best. DO NOT include ancillary photos that are not helpful for diagnosis.
Drop files here or

Max. file size: 2 GB.
Initial Equipment Condition*
Equipment and accessories should should show normal wear. Please check any abnormal conditions and describe unusual conditions below.
- unknown
- System or component under warranty
- Equipment and location satisfactory
- Equipment shows abnormal wear and tear
- Visible accidental or mechanical damage
- Accessories missing or damaged
- Line voltage fluctuates or is out of normal range
- Excessive room temperature or humidity
Hidden
Describe any unusual condition
Comments or Suggestions
Submitted by*
Phone
Email
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Customer Service Request Form

Describe Equipment Needing Service

Who should we contact about the issue?

Where is the equipment requiring service?

What is the issue?

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