Exerpeutic 1111 - PART 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: _________________________________________
“YOUR ORDER WILL BE PROCESSED WITHIN 3 BUSINESS DAYS”
* This form can also be faxed to #: 626-810-2166
PART #
DESCRIPTION
QTY
PART REQUEST FORM
23