Customer information
Practice name
*
Name of dental practice
Location
If there are multiple locations. For example: Irvine
Are you a new customer?
*
Yes
No
New customer information
Contact
*
Best person to speak regarding repairs and sales
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
Email used for billing to send invoice
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type a question
Type option 1
Ticket information
Equipment needing repair (if applicable)
Air compressor
Amalgam separator
Autoclave
Cavitron
Delivery unit
Patient chair
Vacuum
Other
Description of issue
*
Urgency of request
*
Low
Medium
High
Emergency
Preferred date
*
/
Month
/
Day
Year
We will attempt to schedule a technician during the preferred date and window that works best for your practice. High priority and emergency requests may be subject to a higher rate.
Preferred repair window
*
7:00AM - 9:00AM
9:00AM - 12:00PM
12:00PM - 3:00PM
Other
File / images upload
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