Paradigm Health & Wellness, Inc.

PARTS REQUEST FORM

NAME:*

Please input name.
PURCHASER'S NAME:*
   Same as Name.
Please input purchase name.
ADDRESS:*

Please input address.
Apt.#:

Please input Apt.#.
CITY*

Please input city.
STATE*

Please input state.
ZIP*

Please input zip code.
TELEPHONE: (Day)*

Please input telephone number.
(Night)
(Email Address)*

Please input email address. Example: service@paradigmhw.com
SERIAL#*

Please input serial number.
MODEL# 5503
PURCHASE DATE:
Format: mm/dd/yyyy
PURCHASE FROM:
Please provide a copy of Proof of Purchase (e.g. invoice):*   
Please select file for upload.
     I do not have Proof of Purchase but I have registered the product online.
COMMENTS:
PART# DESCRIPTION QTY
001 Backrest
002 Backrest Frame
003 Adjustable Boom
004 Foot Bar
005 Adjustable Instep Frame
006 Handlebar
007 Steel Heel Holder Bracket
008 Rear Frame
009 Front Frame
010 Rod
011 Pivot Arm
012 Handlebar Foam Grip
013 Front Heel Holder
014 Rear Rubber Heel Holder
015 Spring Latch
016 Spring
017 Plastic Spacer
018 Plastic Round End Cap
019 Flat Washer Ø16xØ8.5x1.5
020 Hexagon Socket Head Cap Bolt M8x60mm
021 Nylon Nut M6
022 Rod Cap Ø22
023 Nylon Strap
024 Nut Cap M8
025 Square End Cap □30
026 Ring Pin Ø8x63.5mm
027 Hexagon Socket Head Cap Bolt M8x62mm
028 Hexagon Socket Head Cap Bolt M8x20mm
029 Plastic Washers
030 Foot Bar Oval End Cap
031 Foot Cap
032 Flat Washer Ø13xØ6.5x1.5
033 Bolt M6x12mm
034 Handlebar Round End Cap Ø25
035 Loop Strap
036 Rubber Pad
037 Safety Hook
038 Square End Cap □33
039 Adjustable Instep Frame Round End Cap
040 Adjustable Instep Frame Knob
041 Adjustable Boom Knob
042 Nylon Nut M8
043 Flat Washer Ø16xØ10.5x2.0
044 Metal Bushing
045 Hexagon Head Bolt M8x48mm
046 Hexagon Head Bolt M10x42mm
047 Flat Washer Ø18xØ10.5x2.0
048 Nylon Nut M10
049 Hexagon Head Bolt M6x40mm
050 Flat Washer Ø18xØ6.5x1.5
 

"YOUR ORDER WILL BE PROCESSED WITHIN 3 BUSINESS DAYS"

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