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: