INTER MEDICAL CO., LTD. | SUPPORT | Lumen Dynamics Equipment Service

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■	First Name:
■	Last Name:
■	Company Name:
■	Title:
■	Ship to Address: (Indicate the address where a repaired product would be returned to from Inter Medical)
■	City:
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■	Country:
■	Once you receive the repaired product from Inter Medical, will you be redirecting it to another country?
■	Tel Number:
■	Email:
■	Reason for return:	Calibration Repair Upgrade Credit Return of Demo Lamp Failure Return Used Lamp For Recycling Other

	Please Specify: