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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