Name: Rehab Technology
Address: 9 Palmer Street Balmain, Sydney, NSW, 2041, AU
Telephone: 1300609950

Please fill in a few quick details below with the serial number and any visible error codes so we can provide the best technical support in the shortest amount of time. The support team will be in touch with you within 24 hours.

1Contact Details

Name *

First Last

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Company / Facility Name *

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Please type Personal if you are a home customer
Company Position / Title

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What title do you hold at your facility / company?
Phone Number *

Number

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Must include area code if using a landline - 10 digits required NO Spaces
Alternative Phone Number

Number

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Must include area code if using a landline - 10 digits required NO Spaces
Email *

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Preferred Contact Method

Email Phone

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Address

Street Address Address Line 2 City State/Region/Province Postal / Zip Code

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2Product Details

Brand *

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Please choose your equipment's brand
Model *

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Product Model Number
Serial Number

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Please provide serial number to help resolve your issue more efficiently
Tax Invoice Number

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Please provide your Tax Invoice Number from your equipment purchase and attach your Tax Invoice (on the last page) to claim any applicable Warranties.
Date of Purchase
dd-MMM-yyyy

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Equipment Type

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Choose Equipment to receive the Initial Troubleshooting Steps

3Issue Description

Product Status - Is it still Usable? *

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What is the issue? *

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Additional Description *

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Image Upload

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Maximum 5 Images

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