EPIC Hardware Issue Form

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Terms and Conditions* This field is required.Please provide the requested information so we may be able to determine a solution for your Epic. Please be ready to record video and take a picture of the unit when prompted in the next sections.
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Company Name
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Primary Contact Details* This field is required.
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Date ReceivedPlease provide the date PROTO equipment was first delivered to you.
Date
Year
Month
Day
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Describe the Issue* This field is required.Please explain the nature of the issue / damage and any circumstances that may have lead up to it.
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VideoPlease provide a video of the issue
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Photo* This field is required.Please provide a video of the issue if unable to take a video
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Location Details* This field is required.Current location of unit (where we would pick up the unit or send a replacement tech to).
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Logistics Issues* This field is required.Based on the Epic case dimensions (L 57” W 33.5” H 94.5”) and Epic dimensions (L 53.75" W28.5" H 87.44") is there any additional information that we should be made aware of that may add difficulty to a potential delivery, such as doorways, stairs, tight hallways, low ceilings, etc.? Are there any special insurance requirements for the building it is being delivered to? Any special covid protocols? Please describe below and provide dimensions if there are any potential issues.
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Customs for International ShipmentsIf we ship replacement parts internationally, will you be using your own customs broker or do you want our logistics company to set one up for you (they will be reaching out to the primary contact and bill you directly when the shipment needs to clear customs)?
We will handle customs ourselves
Please provide a customs broker
N/A
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Monitor DisposalIf this is for a potential monitor replacement, are you able to dispose of the old monitor or do you want Proto to arrange for disposal? **Please note that Proto arranging for disposal will cost more than using local options.
We will dispose of the monitor ourselves
We want Proto to arrange disposal
N/A
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Proto Sales Rep* This field is required.Please provide the name of your sales representative
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Additional Comments
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Serial Number* This field is required.Please take a photo of the EPIC's serial number (located on the back bottom panel of the unit).
Should be Empty: