Eyegaze Repair Form

Serial Number *

You can find your serial number on the back of your Eyegaze Edge® tablet, keyboard, or power brick. Devices purchased after 2022 will have 4 digits whereas devices purchased before 2022 will have 8 digits in xxxx-xxxx format.

Your Name

First

Last

Customer's Name *

First

Last

Email *

Phone

Shipping Address

Address Line 1

Address Line 2

City

State

Zip Code

Same as Billing Address?

Yes
No

Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

Does the user have a way continue to communicate while the repair is underway? *

Yes
No

***please note, an additional charge may be added to your repair quote if you require expedited service***

Reason for repair: Please provide as much detail as possible. *

Is there physical damage to the device?

Yes
No

If there is any physical damage, photos are required. *

Click or drag files to this area to upload. You can upload up to 3 files.

If physical damages other than described in this form and shown in the uploaded photos are found, additional charges may be levied.

Would like your repair or exchange to be shipped using expedited shipping? This will significantly increase your shipping cost.

Yes
No

Your repair cannot begin until you have received and approved the repair quote. If your repair is urgent, please call our office at 703-385-8800 once you have submitted this form. *

I agree.

Cookie	Duration	Description
cookielawinfo-checkbox-analytics	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
cookielawinfo-checkbox-functional	11 months	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checkbox-necessary	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-others	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
cookielawinfo-checkbox-performance	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
viewed_cookie_policy	11 months	The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.

Office

Call Us