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PARTS REQUEST FORM
Paradigm Health & Wellness, Inc.
EMAIL THIS FORM WITH YOUR RECEIPT OF PURCHASE TO
Service@paradigmhw.com
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