Medical Equipment Supply & Service
Medical Equipment Service and Repair RGA Form
Please complete the form below to obtain your Return Goods Authorization (RGA) number.
Don't like forms? Call us now at 1-800-658-5582 to get your RGA number
.
Company Name:
*
Account No.:
(4-digit number found on your packing slips and invoices from us)
Contact Name:
*
Contact Phone No.:
*
111-222-3333 format
Contact Email:
*
Call with Estimate:
If we should call someone other than the contact listed above, please provide
that information below:
Estimate Contact Name:
Estimate Contact Phone No.:
Would you like to preapprove your repairs for a certain dollar amount? Preapproval can speed up our average turnaround between 2 and 3 business days. This approval amount will be applied to all equipment shipped in on this RGA number.
Item #1
Device Name/Model:
*
Serial Number:
*
The equipment listed above is in for:
Re-certification
Repair
Pre-approved for:
(Specify dollar amount if desired)
Problem:
Item #2
Device Name/Model:
Serial Number:
The equipment listed above is in for:
Re-certification
Repair
Pre-approved for:
(Specify dollar amount if desired)
Problem:
Item #3
Device Name/Model:
Serial Number:
The equipment listed above is in for:
Re-certification
Repair
Pre-approved for:
(Specify dollar amount if desired)
Problem:
Item #4
Device Name/Model:
Serial Number:
The equipment listed above is in for:
Re-certification
Repair
Pre-approved for:
(Specify dollar amount if desired)
Problem:
Item #5
Device Name/Model:
Serial Number:
The equipment listed above is in for:
Re-certification
Repair
Pre-approved for:
(Specify dollar amount if desired)
Problem:
Item #6
Device Name/Model:
Serial Number:
The equipment listed above is in for:
Re-certification
Repair
Pre-approved for:
(Specify dollar amount if desired)
Problem:
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