Service Intake Form

Instructions: Please provide the following information to assist us with the service of your medical device or technology. Your cooperation will help us diagnose and address the issue as quickly and efficiently as possible. Please ensure the contact information provided below is based on the best contact for this service request.

First Name

Last Name

Practice Name

Relationship with Practice

Group that your practice is associated with (i.e., Disc Centers of America, QC Kinetex, etc.)

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 is required. This information varies by device model but is typically found on the back of the laser after "SN" 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 service process and ensure that we can offer the most appropriate solution to address the issue with your device or technology. Once we receive this Service Intake Form and the Photographs from you, we will be in touch by email within 24-72 hours. Thank you for your assistance.