Equipment Repair Request Form
Please fill out this form and submit prior to sending your equipment.
Request Date
*
-
Day
-
Month
Year
Date
Customer Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Equipment Information
ReproScan Model and Serial Number (if applicable)
Upload photos of the equipment that needs repair (if required/possible)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date of purchase (approx.)
-
Day
-
Month
Year
Date
Has the equipment listed above been repaired for the same issue previously?
*
Yes
No
Was the issue caused by accidental damage like water spill, equipment was dropped?
*
Yes
No
Description of problem and any notes or concerns
*
SUBMIT
Should be Empty: