Customer Information

Practice Name:

Dr. Name (Last, First):

Name of staff submitting form:

Address:

Phone Number:

Fax Number:

E-mail address:

Product Information

Product Type:

( Multiple product types must be submitted on individual forms.)

Product Manufacturer:

Model #:

Serial #:

Quantity of Product:

Reason for Return:

Location of Product in Office:

(ex. OP1, ADMIN1, Dr. Office)

Where is the Product Now?

Date of Purchase:

Pact-One Invoice Number:

Comments:

Disclaimer

Submittal of this form does not guarantee that an RMA will be approved. Upon receipt of this form the Equipment Control department will verify warranty status of products submitted with the manufacturer. If the RMA is approved an e-mail will be sent to the address provided in the form which will include an RMA number and shipping instructions to ship product back to the manufacturer. If the RMA is not approved an e-mail will be sent stating why the RMA was declined.

All shipping costs will be charged to the customer unless they are within the 45 day installation warranty period or are a Platinum service agreement client.

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