REQUEST A TECHNICIAN

Fill in the details below:

Complete and submit the form below to request additional information.
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Note: required fields are denoted with an asterisk(*).

Mailing Address

Office Name

Title

Contact Name

Middle Initial

Last Name

E-mail Address

Address line 1

Address Line 2

Address Line 3

City

ZIP/Postal code

Country

State/province/region

Telephone

Telephone extension (if available)

Mobile

Other Information

Description of Equipment Needing Repair (light, handpiece, x-ray, ect)

Manufacturer (Pelton & Crane, Belmont, Adec, ect.)

Model

Serial number

Was this item purchased from Allstar Dental?

Yes No

Nature of problem

How would you prefer to be contacted to confirm service call?

Email Phone

Who is the contact at office for this repair?

Preferred Time Of Service

Your Second Choice For Time

Additional Comments