Warranty Claim Form

If trouble-shooting has not resolved your issue, complete the warranty claim form below. We will send you a blue envelope to the provided address and ship back your device for servicing or replacement with the provided return label. If your device is not in fact broken (i.e. it is used incorrectly or water damaged), then there will be a charge for shipping and service - depending on the item you are returning

First and Last Name

Phone

Physician Code

Date of Purchase

Serial Number

Doctor Name / Clinic Name

If Troubleshooting Has Already Been Done Yes No

Mailing Address

Short Description of Issue