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# 4153
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
48 Tension Bracket
 

"YOUR ORDER WILL BE PROCESSED WITHIN 3 BUSINESS DAYS"

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