Instructions / Assembly

28
PARTS REQUEST FORM
Paradigm Health & Wellness, Inc.
EMAIL THIS FORM WITH YOUR RECEIPT OF PURCHASE TO
[e-mail]
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
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