Report Issue / Damage to your Product

For reporting a laser issue or damage to your laser product for customers based in the United States.

Account Number:

Practice phone number where equipment resides:

Practice address where equipment resides

Street:

Address 2:

City:

State:

Zip Code:

Country:

Shipping Address different

Street:

Address 2:

City:

State:

Zip Code:

Country:

Contact Name for Shipment:

Contact Phone Number for Shipment:

Contact email for shipment notification:

Device Console Serial Number:

Hand Piece Serial Number:

Was anyone injured due to the damage / issue reported?

Name of person reporting the damage/issue:

Please provide a description of the damage / issue and how the damage / issue occurred:

Please upload/attach photos of the area of console or part damaged for evaluation: