Fax Form - Exerpeutic 1200 Owner's Manual

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
"YOUR ORDER WILL BE PROCESSED WITHIN 3 BUSINESS DAYS"
* This form can also be faxed to #: 626-810-2166
PART REQUEST FORM
20
*
QTY