Service Request

Repair Merchandise Authorization

Complete the form below to request authorization for a device repair. Fields marked with an asterisk (*) are required.

Facility Information

Facility Name*

Address*

Address 2(optional)

City*

State*

Zip*

Customer Information

First Name*

Last Name*

Title*

Direct Phone*

Business Email*

Device Information

Select Your Device*

Serial Number*

Reason*

Device has been disinfectedA $75.00 disinfecting fee applies to all soiled devices

Loaner device is neededWhen service exceeds 10-business days

I agree to the terms and conditions

Signature & Attachments

Digital Signature*

Sign here

Sign with your finger, stylus, or mouse.

Upload Photos or Video(optional)

Images and video files are accepted.

Submitting generates a PDF copy of this request for your records. Our service team will respond with your authorization number and shipping instructions.