Exerpeutic 1301 - Parts Request Fax Form

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Paradigm Health & Wellness, Inc.
PARTS REQUEST FAX FORM
Please fax this form to (1-626-810-2166)
OR YOU CAN EMAIL CUSTOMER SERVICE REQUESTS TO
service@paradigmhw.com
NAME: _________________________________________________________________
ADDRESS: ______________________________________________________________
CITY ______________ STATE ______________ ZIP ___________________
TELEPHONE: (Day) _______________________________________________________
(Night) ______________________________________________________
(Email Address) ______________________________________________
SERIAL#: ___________________________________________________
MODEL#: ___________________________________________________
PURCHASE DATE: _______________________________________________________
PURCHASE FROM: ______________________________________________________
“YOUR ORDER WILL BE PROCESSED WITHIN 3 BUSINESS DAYS”
PART # DESCRIPTION QTY
OFFICIAL USE ONLY
SHIP DATE: ___________________________________________
TRK #: _______________________________________________
BACK ORDER: ________________________________________