Revision Kit Order Form First Name(Required)Last Name(Required)Clinic Name(Required)Email(Required) Delivery Address(Required) Street Address Select the Revision Kit you want to order (if your handpiece is not listed please contact your local EMS Service Provider https://ems-dolorclast.com.au/service-centres/)(Required) EQ-209 EVO BLUE Revision Kit $1,155 Inc GST FR-332 New Blue Revision Kit $1,320 Inc GST Compatible with New RadialCompatible with Smart 10, Smart 20, Master TouchNo revision kit available. Workshop Refurbishment every 600,000k shocks. Request a ServiceNo revision kit available. Workshop Refurbishment every 1 million shocks. Request a ServicePhoneThis field is for validation purposes and should be left unchanged. Service Request First Name(Required)Last Name(Required)Email(Required) Phone/Mobile Number(Required)Clinic Name(Required)Address(Required) Street Address Select your State/Country and Service Provider:(Required)Select your State/Country and Service Provider:ACT - U-Tech MedicalNSW – U-Tech MedicalQLD - U-Tech MedicalSA – HeliconTAS – U-Tech MedicalVIC – U-Tech MedicalWA – MedTeckNew Zealand - Image SpaceSelect your required service:(Required)Select your required service:Repair or BreakdownAnnual ServiceWorkshop RefurbishmentSelect your Device/s:(Required) DolorClast Classic DolorClast Master DolorClast Radial DolorClast Smart10 DolorClast Smart20 How many DolorClast Classic devices do you have?(Required)12345How many DolorClast Master devices do you have?(Required)12345How many DolorClast Radial devices do you have?(Required)12345How many DolorClast Smart10 devices do you have?(Required)12345How many DolorClast Smart20 devices do you have?(Required)12345Select your Handle/s:(Required) EvoBlue Blue Power+ Select your Handle Type:(Required) EvoBlue Workshop Refurbishment Blue Workshop Refurbishment Power+ Workshop Refurbishment Standard Workshop Refurbishment Enter shock count for EvoBlue Handpiece(Required)Recommended every 5 million shocksEnter shock count for Blue Handpiece(Required)Recommended every 5 million shocksEnter shock count for Power+ Handpiece(Required)Recommended every 600k shocksEnter shock count for Standard(Required)Recommended every 1 million shocksPlease specify your issue:(Required)Preferred Time:(Required)Preferred Time:immediatelyin 1-2 monthsin 3-4 monthsin 4+ monthsnot right nowAdditional Comments
