Paradigm Health & Wellness, Inc.
PARTS REQUEST FAX FORM
Please fax this form to (1-626-810-2166)
OR YOU CAN EMAIL CUSTOMER SERVICE REQUESTS TO
NAME:
_______________________________________________________
ADDRESS:
____________________________________________________
CITY ______________ STATE ______________ ZIP ___________________
TELEPHONE: (Day) _____________________________________________
(Night) ____________________________________________
(Email Address) ____________________________________
SERIAL#: __________________________________________
ITEM/MODEL#: _____________________________________
PURCHASE DATE: ______________________________________________
PURCHASE FROM:
______________________________________________
“YOUR ORDER WILL BE PROCESSED WITHIN 3 BUSINESS DAYS”
PART #
DESCRIPTION
REASON
QTY
OFFICIAL USE ONLY (MD)
SHIP DATE: ___________________________________________
TRK #: _______________________________________________
BACK ORDER: ________________________________________
27
FAX FORM
