2
Complaint Form
☐
Troubleshooting was attempted and could not resolve the issue
Document the following information below. Do not leave blank fields
.
Convey Representative Name
Customer Name
Customer Phone Number
Customer Address
Customer Email Address
Item Number
G30270AH
Optum Item number
2692
Age of Product (estimated)
Product Serial or Lot Number
Photo Available?
Defect Code
Check as many error codes are applicable
to the customer issue.
☐
Defect Code 1
☐
Defect Code 2
☐
Other: Please explain __________