Parts Request Form - Exerpeutic 1317.5-101016 Owner's Manual

PARTS REQUEST FORM

Paradigm Health & Wellness, Inc.
EMAIL THIS FORM WITH YOUR RECIEPT OF PURCHASE TO
Service@paradigmhw.com
NAME: _______________________________________________________
ADDRESS: ____________________________________________________
CITY ______________ STATE ______________ ZIP ___________________
TELEPHONE: (Day) _____________________________________________
(Night) ____________________________________________
SERIAL#: _____________________________________________________
MODEL#: _____________________________________________________
PURCHASE DATE: ______________________________________________
PLACE OF PURCHASE: _________________________________________
PART # DESCRIPTION QTY
"YOUR ORDER WILL BE PROCESSED WITHIN 3 BUSINESS DAYS"
*This form can also be faxed to #: 626-810-2166
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