Exerpeutic WorkFit - 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
25
PART REQUEST FORM