Sell Your Equipment

Please call us to discuss your equipment, or fill out the form below and send to us and we will contact you regarding your equipment.

Please complete this form to the best of your abilities. We will request photos upon receipt and acceptance of this form.

Practice / Business Name: *

Physician/ Owner Name: *

E-mail: *

Phone Number: *

Fax

Product Verification/Inspection

Manufacturer:

Manufacturing Date:

Model:

Serial Number:

Total System Hours or Pulses:

Hardware Checklist

Physical Condition / Appearance:

List Hand Pieces and Corresponding Shot Counts:

Eyewear (Number Available):

Additional Accessories (i.e. Owner’s Manual, DVDs, etc):

Service Details

Previous OEM Reports (Available?): Yes No

Last Date of Service:

Factory Warranty Details:

System Details

Is this equipment SAFE for treating patients? Yes No Unsure

Additional comments and information:

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