Exerpeutic TF2000 - Parts Request Form

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PARTS REQUEST FORM
Paradigm Health & Wellness, Inc.
EMAIL THIS FORM WITH YOUR RECEIPT 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 in Fax #: 626-810-2166
PART # DESCRIPTION QTY