Repairs – Salvin Dental Specialties

Salvin Repair Information Form

Doc. No: 1100-2F Rev. No: B

3450 Latrobe Drive, Charlotte, NC 28211 / 800-535-6566 / [email protected]

Your Office Information

Doctor's Name

Contact Person

Phone Number

Customer Number

Email Address

Invoice Number

Address

*Please provide your email address so we can send you the evaluation and cost of the repair.

Please list each item you are sending in for repair along with any applicable serial or lot numbers. Describe in as much detail as possible the nature of the issue or problem you are having with the item(s).

Item #1

Lot or Serial #1

Reason for Repair #1

Item #2

Lot or Serial #2

Reason for Repair #2

Item #3

Lot or Serial #3

Reason for Repair #3

Item #4

Lot or Serial #4

Reason for Repair #4

Item #5

Lot or Serial #5

Reason for Repair #5

Please answer the following questions:
YesNo #1 - Is the issue a deficiency related to the identity, quality, durability, reliability, safety, effectiveness, or performance of the item? (Note for Salvin: If “Yes”, initiate complaint)
YesNo #2 - Was a patient involved when the issue or problem occurred?
YesNo #3 - If YES to #2, were there any adverse patient effects?
#4 - If YES to #3, please explain Below:

I hereby attest that the instruments being returned to Salvin Dental Specialties, Inc. have either been (check one):

Sterilized in accordance with their Instructions for Use. ORHave not been clinically used*.
**Process products per 1088P

Upon receiving your repair, an evaluation of the problem will be made. The evaluation period could take up to two weeks. We will reply to you with the evaluation as soon as possible.

Please ship package to:
Salvin Dental Attn: Repair Department 3450 Latrobe Drive Charlotte, NC 28211

Suggestions for shipping:
- Please use proper packaging to avoid damage or loss of product during transit. - If possible, ship by a courier that provides a tracking number. - Salvin Dental Specialties does not pay for repair shipping.

Conditions:
**We accept returns or exchanges for unused/unopened regenerative products and instruments that have not been used or autoclaved only. We will issue a full refund excluding freight charges in the same method as original purchase unless a replacement item is provided. **Upon receiving your return, we will evaluate it to determine usage and if used, the item will be returned to you. Salvin Dental Specialties does not pay for return shipping.