DEVICE REPAIR REQUEST FORM

Welcome Imagin Partner

Partner / Rep Name * Contact Person *

This person will be our main office contact for this repair. Can find repairs by this name

This email and phone will be our primary ways to provide updates

Delivery Address *

Ship-To Address * Return repaired device to delivery address above Return repaired device direct to dental customer's address

Please complete all required fields above.

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1Step 1: Dental Office & Contact Information

2Step 2. Device Information

3Step 3. Print Form, Include, & Submit

Dental Office or Practice / Company Name

Doctor’s Name

First

Last

We ask for this name to more easily find your repair ticket by doctor's name if you call us

Doctor Email

Office Contact Person

Same as Doctor Info
Separate Contact

Office Contact Person

First

Last

This office person will be our main point of contact instead of the doctor's name and email

Office Contact Email

This email will be used for all repair updates and communication.

Dentist Office Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Imagin provides a ground shipping label only for US-based addresses.

Office Phone Number

Mobile Phone Number

Dental Device Type

X-Ray Sensor Brands

3D Scanner Brands

Intraoral Camera Brands

Device Serial Number

Write N/A if you cannot find a device serial number

Select one or more device issues from the list below

Connection Issue – Disconnects when moved
Ready in software, doesn’t populate image when exposed
Unrecognized device error
Does nothing when plugged in – completely dead
Artifact / crack or dark spots in image
Auto-fires bad / static images
USB connector / plug broken
Cable issue: broken, exposed, split, creased
Cracked casing / shell
Cracked lens (3D scanners & IO cameras)
Other issue not listed

Description of Problem(s)

Please describe other problem(s) you are experiencing with your device

Accessories being shipped with your device:

USB Cable
Software: Disc/Thumb drive
Laptop
Docking station

Check 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)

X Ray Sensor Brands (Device 2)

3D Scanner Brands (Device 2)

Intraoral Camera Brands (Device 2)

Device 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 moved
Ready in software, doesn’t populate image when exposed
Unrecognized device error
Does nothing when plugged in – completely dead
Artifact / crack or dark spots in image
Auto-fires bad / static images
USB connector / plug broken
Cable issue: broken, exposed, split, creased
Cracked casing / shell
Cracked lens (3D scanners & IO cameras)
Other issue not listed

Description 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 Cable
Software: Disc/Thumb drive
Laptop
Docking station

Check all that apply

Device’s Imaging Software (Device 2)

I.e. Eaglesoft, Dexis, VixWin, Apteryx (for X-Ray sensors)

Add Another Device? (Third)

Add another device?

Dental Device Type (Device 3)

X Ray Sensor Brands (Device 3)

3D Scanner Brands (Device 3)

Intraoral Camera Brands (Device 3)

Device Serial Number (Device 3)

Write N/A if you cannot find a device serial number

Select one or more device issues from the list (Device 3)

Connection Issue – Disconnects when moved
Ready in software, doesn’t populate image when exposed
Unrecognized device error
Does nothing when plugged in – completely dead
Artifact / crack or dark spots in image
Auto-fires bad / static images
USB connector / plug broken
Cable issue: broken, exposed, split, creased
Cracked casing / shell
Cracked lens (3D scanners & IO cameras)
Other issue not listed

Description of Problem(s) (Device 3)

Please describe other problem(s) you are experiencing with your device

Accessories being shipped with your device (Device 3):

USB Cable
Software: Disc/Thumb drive
Laptop
Docking station

Check all that apply

Device’s Imaging Software (Device 3)

I.e. Eaglesoft, Dexis, VixWin, Apteryx (for X-Ray sensors)

Add Another Device? (Fourth)

Add another device?

Device Single list

Dental Device Type (Device 4)

X Ray Sensor Brands (Device 4)

3D Scanner Brands (Device 4)

Intraoral Camera Brands (Device 4)

Device Serial Number (Device 4)

Write N/A if you cannot find a device serial number

Select one or more device issues from the list (Device 4)

Connection Issue – Disconnects when moved
Ready in software, doesn’t populate image when exposed
Unrecognized device error
Does nothing when plugged in – completely dead
Artifact / crack or dark spots in image
Auto-fires bad / static images
USB connector / plug broken
Cable issue: broken, exposed, split, creased
Cracked casing / shell
Cracked lens (3D scanners & IO cameras)
Other issue not listed

Description of Problem(s) (Device 4)

Please describe other problem(s) you are experiencing with your device

Accessories being shipped with your device (Device 4):

USB Cable
Software: Disc/Thumb drive
Laptop
Docking station

Check all that apply

Device’s Imaging Software (Device 4)

I.e. Eaglesoft, Dexis, VixWin, Apteryx (for X-Ray sensors)

Add Another Device? (Fifth)

Add another device?

Dental Device Type (Device 5)

X Ray Sensor Brands (Device 5)

3D Scanner Brands (Device 5)

Intraoral Camera Brands (Device 5)

Device Serial Number (Device 5)

Write N/A if you cannot find a device serial number

Select one or more device issues from the list (Device 5)

Connection Issue – Disconnects when moved
Ready in software, doesn’t populate image when exposed
Unrecognized device error
Does nothing when plugged in – completely dead
Artifact / crack or dark spots in image
Auto-fires bad / static images
USB connector / plug broken
Cable issue: broken, exposed, split, creased
Cracked casing / shell
Cracked lens (3D scanners & IO cameras)
Other issue not listed

Description of Problem(s) (Device 5)

Please describe other problem(s) you are experiencing with your device

Accessories being shipped with your device (Device 5):

USB Cable
Software: Disc/Thumb drive
Laptop
Docking station

Check all that apply

Device’s Imaging Software (Device 5)

I.e. Eaglesoft, Dexis, VixWin, Apteryx (for X-Ray sensors)

Select 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 option

Quote-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 us

UPS Ground
USPS Ground

Suggested Shipping Box Sizes — Use USPS or UPS

Priority Small Box

X-Ray sensors only

Priority Small Box
~5-1/2" x 1-3/4" x 8-5/8"

Priority Medium Box

X-Ray Sensor(s), & a 3D Scanner or Intraoral Camera

Priority Medium Box
~11-3/4" x 8-3/4" x 5-3/4"

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.

Single Line Text

DEVICE REPAIR REQUEST FORM

DEVICE REPAIR REQUEST FORM

Suggested Shipping Box Sizes — Use USPS or UPS

If Your Device Cannot Be Repaired:

By SUBMITTING THIS FORM, I understand and agree to all the terms and conditions of this repair contract.

650-596-1001

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