HOST - Service Request
 1. Location · 2. Instruments · 3. Summary

LOCATION 1
*Required field
TIME FOR SERVICE
Please select the best time for service

Practice Name: *
Doctor's Name: *
Street Address: *
City: *
State: *
Postal Code: *
Email: *
Phone: *
Fax:
Day: Time:

Haag-Streit will make every effort to work within your schedule. Please note that technicians will take about one hour to service every major piece of equipment. Service schedules are made several months in advance. Any cancellations made after your office is scheduled is subject to a $100 administration fee.

COMMENTS
Please enter other comments about your service request including model number and serial number.