Handpiece Repair Request
Customer Information
Practice Name
*
Contact Name
*
First Name
Last Name
Email
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pickup Information
Preferred UPS Pickup Date
*
/
Month
/
Day
Year
Date
Available UPS Pickup Time Windows (Select both for All Day availability)
*
8:00AM - 12:00PM
12:00PM - 5:00PM
Shipping Information
Pick Up and Return Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Service Request
Repair Priority
*
Standard – No immediate need.
Priority – Need returned as soon as reasonably possible.
Rush – Critical; patient scheduling is being affected.
Proceed with repairs up to:
*
$100
$200
$300
$500
Contact me before any repair
Handpiece Information
Handpiece Details
*
Additional Notes & Photos
Upload Photos (Optional)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Special Instructions (Optional)
Shipping Label and Delivery
Where should we send your UPS shipping label?
*
Use email address provided above
Send to a different email address
Alternate Shipping Label Email
*
example@example.com
Terms & Authorization
Authorization
*
I authorize QDS to coordinate repair services on my behalf.
I understand repairs exceeding my approval limit will require authorization before work begins
Submit
ASANA TASK NAME
Date of Request
-
Month
-
Day
Year
Date
Should be Empty: