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Paradigm Health & Wellness, Inc.
EMAIL THIS FORM WITH YOUR RECIEPT 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 in Fax #: 626-810-2166
DESCRIPTION
QTY
PART REQUEST FORM
PART #
Summary of Contents for 8103
Page 2: ...1 8103 3 060716 ...
Page 6: ...5 IMPORTANT LABELS ...