Repair Intake Form

First Name

Last Name

Practice Name

Practice Location

Group that your practice is associated with (i.e., Disc Centers of America, QC Kinetex, etc.) —Please choose an option—Disc Centers of AmericaQC KinetexOther

Phone Number

Email Address

Shipping address for your device after it is repaired

Special instructions, if applicable (Please include any special delivery instructions. Signature upon receipt of shipment is required)

Device Purchase Date (If you have the invoice from the initial purchase, please include in email with this form)

Device Model Name (i.e., Medray Quad Laser) (This information varies by device model but is typically found on the label under the device or within the device settings under “Information”)

Device Serial Number (This information varies by device model but is typically found on the label under the device or within the device settings under “Information”)

Description of the issue with your device (Please describe in as much detail as possible the problem you are experiencing with the device. Example: "Laser not powering on when I plug it into the outlet", “When I turn laser on to use it, the screen does not work”, etc.)

Actions taken to resolve issue, if any

Specific events leading up to the issue (Please provide a brief description of any events/circumstances that may have led to the issue, including any recent incidents, maintenance, power surges, or usage changes)

Photographs of the issue and device. (Please provide at least 2-3 photographs of the device issue you are dealing with and of the entire device. These images play a critical role in assisting our expert technicians to better understand the problem and address it more quickly)

By providing this information, you will help our team expedite the repair process and ensure that we can offer the most appropriate solution to address the issue with your device. Once we receive this Repair Intake Form and the Photographs from you, we will be in touch within 24-48 hours. Thank you for your assistance.