Dental Scanner Performance Claim Submission Form
Submit details about a dental scanner performance issue so the claim can be reviewed. Please provide accurate device, issue, and evidence information.
Claimant Information
Full Name
*
First Name
Middle Name
Last Name
Company / Clinic Name
*
Role / Department
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
Either
Scanner Device Details
Scanner brand or manufacturer
*
Model name or number
*
Serial number or device identifier
Date of purchase or installation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current firmware or software version
Clinic, site, or location where the scanner is used
*
Claim Details and Performance Issue
Date issue first occurred
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is the issue ongoing?
*
Yes
No
Issue frequency
*
Once
Intermittent
Frequent
Constant
Performance issue category
*
Please Select
Accuracy
Speed
Calibration
Connectivity
Image Quality
Software Crash
Other
Impacted scan type(s)
*
Full arch
Quadrant
Single tooth
Bite scan
Implant scan
Other
Detailed issue description
*
Error messages or codes observed
Steps already tried to troubleshoot
Primary scanner workflow affected
Estimated number of affected scans
Evidence and Resolution Request
Supporting Evidence Files
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Preferred Resolution or Outcome
*
Troubleshooting support
Replacement
Repair
Software update
Return/material review
Other
Additional Comments
Confirmation of Accuracy and Completeness
*
I confirm that the information provided is accurate and complete to the best of my knowledge.
Submit Claim
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