DEVICE REPAIR REQUEST FORMPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.1Step 1: Your Office & Contact Info2Step 2. Your Device Information3Step 3. Print Form, Include, & SubmitDental Office or Practice / Company Name *Doctor’s Name *FirstLastWe ask for this name to more easily find your repair ticket by doctor's name if you call us Office Email *EmailConfirm EmailOffice Contact PersonSame as Doctor InfoSeparate ContactOffice Contact PersonFirstLastThis office person will be our main point of contact instead of the doctor's name and email Office Contact EmailEmailConfirm EmailThis email will be used for all repair updates and communication.Dentist Office Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeSelect Country from dropdownAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryImagin provides a ground shipping label only for US-based addresses.Office Phone Number *Mobile Phone Number *NextDental Device Type Select the type of device to repair from the dropdownX-Ray SensorIntraoral Camera3D ScannerX-Ray Sensor BrandsSelect the brand-model of your X-Ray sensor from the dropdownDexis PlatinumDexis TitaniumSchickSirona CDRSchick CDR EliteSchick 33 Shick Sirona XiosSchick AEKodak Carestream RVG5100Kodak Carestream RVG5200Kodak Carestream RVG6000Kodak Carestream RVG6100Kodak Carestream RVG6200Gendex GXS-700Kavo IXSKavo ProXam iS XDRCARINAClearVision EVA SOPIX 1amp2Planmeca Planmeca ProSensorHDOwandy OpteoApex Dentimax Dream SensorSuniray Suniray2Suni IQ QuickRayDenttio TioH Clio Prime3D Scanner BrandsSelect the brand-model of your 3D scanner from the dropdown3Shape Trios Core Wired3Shape Trios 3 Wired3Shape Trios 5 Wireless3Shape Trios 6 WirelessMedit i500Carestream 3600Carestream 3700CEREC PrimeScanHelios 500Dexis IS 3600Shining 3D Aoralscan 3Planmeca Planscan Intraoral Camera Brands Select the brand-model of your intraoral camera from the dropdownKodak 1500 Intraoral CameraDEXcam Intraoral CameraAir Techniques AcclaimAir Techniques Polaris Insight 090Insight 2020ImageMasterDocPortDevice Serial Number Write N/A if you cannot find a device serial number from Brands Dental Select one or more device issues from the list belowConnection Issue – Disconnects when movedReady in software, doesn’t populate image when exposedUnrecognized device errorDoes nothing when plugged in – completely deadArtifact / crack or dark spots in imageAuto-fires bad / static imagesUSB connector / plug brokenCable issue: broken, exposed, split, creasedCracked casing / shellCracked lens (3D scanners & IO cameras)Other issue not listedDescription of Problem(s) Please describe other problem(s) you are experiencing with your device Accessories being shipped with your device:USB CableSoftware: Disc/Thumb driveLaptopDocking stationCheck all that apply Device’s Imaging Software I.e. Eaglesoft, Dexis, VixWin, Apteryx (for X-Ray sensors) Add Another Device?Add another device?Dental Device Type (Device 2)Select the type of device to repair from the dropdownX-Ray SensorIntraoral Camera3D ScannerX Ray Sensor Brands (Device 2)Select the brand-model of your X-ray sensor from the dropdownDexis PlatinumDexis TitaniumSchickSirona CDRSchick CDR EliteSchick 33 Shick Sirona XiosSchick AEKodak Carestream RVG5100Kodak Carestream RVG5200Kodak Carestream RVG6000Kodak Carestream RVG6100Kodak Carestream RVG6200Gendex GXS-700Kavo IXSKavo ProXam iS XDRCARINAClearVision EVA SOPIX 1amp2Planmeca Planmeca ProSensorHDOwandy OpteoApex Dentimax Dream SensorSuniray Suniray2Suni IQ QuickRayDenttio TioH Clio Prime3D Scanner Brands (Device 2)Select the brand-model of your device from the dropdown3Shape Trios Core Wired3Shape Trios 3 Wired3Shape Trios 5 Wireless3Shape Trios 6 WirelessMedit i500Carestream 3600Carestream 3700CEREC PrimeScanHelios 500Dexis IS 3600Shining 3D Aoralscan 3Planmeca Planscan Intraoral Camera Brands (Device 2)Select the brand-model of your device from the dropdownKodak 1500 Intraoral CameraDEXcam Intraoral CameraAir Techniques AcclaimAir Techniques Polaris Insight 090Insight 2020ImageMasterDocPortDevice Serial Number (Device 2)Write N/A if you cannot find a device serial number Select one or more device issues from the list (Device 2)Connection Issue – Disconnects when movedReady in software, doesn’t populate image when exposedUnrecognized device errorDoes nothing when plugged in – completely deadArtifact / crack or dark spots in imageAuto-fires bad / static imagesUSB connector / plug brokenCable issue: broken, exposed, split, creasedCracked casing / shellCracked lens (3D scanners & IO cameras)Other issue not listedDescription of Problem(s) (Device 2)Please describe other problem(s) you are experiencing with your device Accessories being shipped with your device (Device 2):USB CableSoftware: Disc/Thumb driveLaptopDocking stationCheck all that apply Device’s Imaging Software (Device 2)I.e. Eaglesoft, Dexis, VixWin, Apteryx (for X-Ray sensors) PreviousNextSelect a repair process option Standard Pre-approved up to $1,000 repair: Saves 1-2 days of time. We contact you if the repair costs more or device is non-repairable.Quote-based repair: Typical 3-5 day repair time (excludes ship time).Select a repair process optionQuote-based repair: Typical 3-5 day repair time (excludes ship time).Select a Warranty Option for Repair Standard 6-month Warranty ( Free ) – Parts and labor on the work Imagin does.12-Month Extended Warranty ( +$600)Select option to ship your device to usUPS Ground (Imagin pays US only)USPS Ground (Imagin pays US only)I'll ship it using my Carrier Before You Ship Your Device: • Print this form and include it in your package • Carefully package your device to prevent damage • Add shipping insurance (recommended: $1,000 per device) Shipping Responsibility: You are responsible for shipping your device to us using your preferred carrier or the ground UPS or USPS label Imagin is not responsible for tracking devices or devices carriers lose during transit. Shipping from outside the U.S.? • Use Reason for Export: REPAIR & RETURN • Avoid declaring full value (will trigger high tariffs) • Tariff codes available if needed: Canada: 9813.00.0540 UK: 9813.00.05 • Contact: sales@imaginrepair.com If Your Device Cannot Be Repaired: A $75 evaluation fee applies to return your device. Devices not claimed within 90 days will be discarded. By SUBMITTING THIS FORM, I understand and agree to all the terms and conditions of this repair contract. PreviousSubmit
