SERVICE REQUEST FORM

Submit a Service & Repair Request

Complete the form below to request a service evaluation. Our team will review your information and contact you regarding available options.

Complete the Form

Provide your contact information, equipment details, and describe the problem.

We Review Your Request

Our team evaluates the information you've provided to determine available options.

We Contact You

We'll reach out to discuss available options and next steps for your situation.

⚠ Service request submission is not enabled in this staging preview. No request has been submitted.

Service Request Received

Thank you. Our team will review your request and contact you regarding available next steps.

Customer Information

First Name

Last Name

Email Address

Phone Number

Service Location

State

ZIP Code

Street Address (optional)

Apt / Suite (optional)

City (optional)

Equipment Information

Equipment Type

Purchased from Gilgal Medical?

Yes No Not Sure

Manufacturer (optional)

Model Name (optional)

Serial Number (optional)

Approximate Year Purchased (optional)

Problem Description

Describe the Problem

Is your equipment currently usable? (optional)

Yes, still usable Partially No, not usable

Error Code Displayed (if any)

Attachments (optional)

Photos and documents help us evaluate your request more quickly but are not required. JPG, PNG, or PDF only. Maximum 3 MB per file, 3.5 MB combined.

Equipment Photo

Upload equipment photo JPG, PNG, PDF · max 3 MB

Serial Number Label

Upload serial number label JPG, PNG, PDF · max 3 MB

Damaged Component Photo

Upload damage photo JPG, PNG, PDF · max 3 MB

Supporting Document

Upload supporting document Warranty, receipt, or other documentation · max 3 MB

Consent & Submit

Submitting this form is a request for evaluation only and does not confirm service availability, warranty coverage, or authorization of paid work. Do not ship or transport your equipment until contacted by Gilgal Medical with specific instructions.

Need help? (855) 228-3625

Your information is used only to review and process your service request. We do not share your personal information with third parties.

Need to Reach Us Directly?

Our team is available to answer questions about the service request process.

(855) 228-3625