Submit Your Case

Account Number:

STREET:
ADDRESS 2:
CITY:
STATE:
ZIP CODE:
COUNTRY:
CHECK IF SHIPPING ADDRESS IS DIFFERENT FROM PRACTICE ADDRESS ABOVE
SHIPPING STREET
SHIPPING ADDRESS 2
SHIPPING CITY 
SHIPPING STATE
SHIPPING ZIP CODE
SHIPPING COUNTRY

CONTACT PHONE NUMBER FOR SHIPMENT:

DEVICE CONSOLE SERIAL NUMBER
HAND PIECE SERIAL NUMBER:
WAS ANYONE INJURED DUE TO THE DAMAGE / ISSUE REPORTED:
NAME OF PERSON REPORTING THE DAMAGE / ISSUE: