21
PARTS REQUEST FORM
Paradigm
Health & Wellness
, Inc.
EMAIL THIS FORM WITH YOUR RECEIPT OF PURCHASE TO
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
