SurgiTel | Loupe and Light Repair Form -

Submit repair request with the form below to begin process.
Be sure to include a copy of your confirmation email received after submitting your request with your shipment.
Thoroughly clean and disinfect your loupes. SurgiTel may charge cleaning fee if product is deemed unsanitary or unsafe.
Please do not include third-party products.
Package your loupes safely and in appropriate shipping materials inside a box in preparation for shipment.
Keep a copy of your shipping receipt for your own records.

Ship your packaged loupes/light to:

First Name (required)

Last Name* (Required)

Your Email* (Required)

Your Cell Phone* (Required)

Office Phone

Street Address

Street Address 2

City

State / Province

Zip / Postal Code* (Required)

Country* (Required)

Profession

What is the best way to reach you?

Cell PhoneText MessageEmailOffice

Describe what needs to be repaired.* (Required)

Do you have any special instructions?

YesNo

Special Instructions

Attach an image showing product.* (Required)