Submit Your Handpiece Repairs with Ease

Sending in your repair is quick and easy.

Fill out the digital form below or print the form and include it with your order.

Handpiece Repair Request Form

Please fill out your information.

Office or Practice Name

First Name

Last Name

Date

MM

DD

YYYY

Phone

(###)

###

####

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Would you like an estimate?

*Estimate delays repairs by 24 hours

No - Please start my repair

Yes - I would like a free estimate

How did you hear about us?

Web Search

Print Mailer

Online Ad

Event/Conference

Referral

Other

Handpiece

Serial #

Problem

Handpiece 2

Serial # 2

Problem 2

Handpiece 3

Serial # 3

Problem 3

Handpiece 4

Serial # 4

Problem 4

Handpiece 5

Serial # 5

Problem 5

Promo Code