Digital Imaging Support Request

Digital Imaging Support Request

** WE ARE UNABLE TO PROVIDE SUPPORT FOR ANY OPG / CBCT or 3D IMAGING**
Practice Name*
Please ensure this is your correct billing name
Contact Person*

First NameLast Name
Phone*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please briefly explain your issue:*
Please upload any errors or relevant screen shots.

Cancelof
Patient Management System*

D4WOasisExactPraktikaOther
Current Imaging Software*
Product*

CarestreamDuerrOther
Model*

CS1200CS1500 WirelessCS1500 WiredCS7200CS7600Other
How Many PC's Require Install?*
Preferred Install Date & Time*

DayMonthYear
Date
Hour Minutes

AM/PM Option
IT Support Details
Do you have day to day IT Support?*

YesNo
To help us better support you, please provide the details of the person/ company who usually assists with your day to day IT support.
IT Company
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Current Anti Virus System
Support is available during standard business hours (8:30am - 5:00pm AEST)

+ Standard support @ $200 + GST p/h. billed in 15min increments for remote, min 1hr for onsite.
+ Travel charged @ $100 + GST p/h.
+ Non standard support or projects may be billed separately
+ Parking expenses on charged to client
+ After hours and emergency support available @ $280 + GST p/h (minimum 1hr)

*PLEASE NOTE*
Support is considered and includes any verbal or digital troubleshooting / evaluation and remediation phone calls, emails & text messages.

A credit card is required prior to any works being commencing. Please note: Your card will not be charged until works are completed. *

I have read and understand the above

$1.00AUD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Digital Imaging Support Request

IT Support Details