Paradigm Health & Wellness, Inc.
EMAIL THIS FORM WITH YOUR RECIEPT OF PURCHASE TO
NAME: _______________________________________________________
ADDRESS: ____________________________________________________
CITY ______________ STATE ______________ ZIP ___________________
TELEPHONE: (Day) ____________________________________________
SERIAL#: _____________________________________________________
MODEL#: _____________________________________________________
PURCHASE DATE: _____________________________________________
PLACE OF PURCHASE: _________________________________________
PART #
DESCRIPTION
"YOUR ORDER WILL BE PROCESSED WITHIN 3 BUSINESS DAYS"
* This form can also be faxed in Fax #: 626-810-2166
PART REQUEST FORM
Service@paradigmhw.com
(Night) ____________________________________________
29
*
QTY