Dermatome Repair Form

Padgett Dermatome Repair Request Form

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Contact Name *

First

Last

Company Name *

Contact Information

Email *

Phone *

Bill To Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Ship To Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Ship to address is same as billing

• Yes
• No

Shipping

How do you want your return shipped? *

• Please ship via UPS and bill me
• Please use the shipping account number I have included

Please provide shipping courier and account number:

Equipment Information Item #1

Handpiece, Power Supply or Other *

• Handpiece
• Power Supply
• Other

Model Number *

Enter N/A if no model number is available

Serial Number *

Enter N/A if no serial number is available

item Ship To

Troubles Experiencing Item #1

e.g. will not turn on, weak cutting, burning smell, needs new cord.

Contact me with estimate item #1

• Contact me with an estimate.
• Please contact me if repair is over $450.
• If repair is under $450 go ahead and repair.

Equipment Information Item #2

Handpiece, Power Supply or Other

• Handpiece
• Power Supply
• Other

Model Number

Enter N/A if no model number is available

Serial Number

Enter N/A if no serial number is available

Troubles Experiencing Item #2

e.g. will not turn on, weak cutting, burning smell, needs new cord.

Contact me with estimate item #2

• Contact me with an estimate.
• Please contact me if repair is over $450.
• If repair is under $450 go ahead and repair.

Equipment Information Item #3

Handpiece, Power Supply or Other

• Handpiece
• Power Supply
• Other

Model Number

Enter N/A if no model number is available

Serial Number

Enter N/A if no serial number is available

Troubles Experiencing Item #3

e.g. will not turn on, weak cutting, burning smell, needs new cord.

Contact me with estimate item #3

• Contact me with an estimate.
• Please contact me if repair is over $450.
• If repair is under $450 go ahead and repair.

Purchase Order

Purchase Order Number

Morta Medical does not require a purchase order number, this is for your accounting if needed.

File Upload

Drag & Drop Files, Choose Files to Upload

If you need to include a copy of your purchase order or if you have photos you need to upload, you can do it here.

Florida Sales Tax Certificate Upload

Drag & Drop Files, Choose Files to Upload

We are only required to collect Sales Tax for Florida purchases. If you are Florida Sales Tax exempt, you can upload your certificate. You only have to do this once a year.

Submit

Consider purchasing one of our Morta Medical brand replacement power supplies to have on hand as a back-up or just replace your old one. We make them up in 120v AC and 230v AC. The parts we use are the same or better than the older OEM’s.

Morta Medical, LLC is not affiliated with Integra/Padgett.