Instructions / Assembly

27
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
QTY