Maintenance Request - Top Quality Group

Customer info (please choose category)*

Distributor

Doctor/Clinic

Distributor Company Name*

Contact person*

ㅤ First name Last name

Email (Reference for Maintenance)*

Telephone*

Doctor/Clinic Full Name*

Contact person*

ㅤ First name Last name

Email*

Telephone*

Location and address*

Full Address City State / Province / Region ZIP / Postal Code Country

Same address for deliveries?*

Yes

No

Delivery address*

Full Address City State / Province / Region ZIP / Postal Code Country

Please make sure you have the device label at you disposal; it is located on the side of the device.

Device label photo*

Drop files here or

Max. file size: 32 MB.

PLC number*

PLC Number is on the label of the device

Attachments*

Pictures or videos of the problem

Drop files here or

Max. file size: 32 MB.

Issue with*

Accessories

Device

Describe the issue*