PhotoMed Repair Request Form

In order to process your repair as quickly as possible, please enter your information below. When finished, please click the "Continue" button at the bottom of the page.

If you have any questions, you can call us at 800-998-7765 (U.S. & Canada) or 818-908-5369.

Doctor's Name (who purchased the camera equipment) Doctor's Name (who purchased the camera equipment) * First Last
Contact Name (if other than the doctor) Contact Name (if other than the doctor) First Last
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone - best daytime number to reach you Phone - best daytime number to reach you * - ### - ### ####
Email Address

PLEASE check that the email address is correct as this is how we will contact concerning your repair status *
If eligible, would you like to be contacted about loan equipment while your item is being repaired? *

If eligible, would you like to be contacted about loan equipment while your item is being repaired? Yes, please contact me No, I do not need a loaner No, a loaner has already been arranged
Repair Details

Enter the name and model number of the item(s) that need service below:
Item #1
Product Name and Model Number that needs repair *
Item #2
Product Name and Model Number that needs repair
Item #3
Product Name and Model Number that needs repair
Describe the issue that you are having *

PhotoMed Repair Request Form

PhotoMed Repair Request Form

Repair Details