Return Goods Authorization (RGA) Request Form

Contact Information

Name *

First

Last

Company *

Account Number

Email *

Additional Email

Add an additional email to be copied on the confirmation email.

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Device Information

When you have multiple devices, upload a file listing the model and/or serial numbers and the corresponding issues. If uploading a file, enter
See attachment for the required fields Model Numbers(s) and Issue.

Provide images if the device arrived damaged.

You can also upload images to help show the issue with your device.

Model Number(s): *

Serial Number(s):

Issue: *

File Upload

Click or drag files to this area to upload. You can upload up to 10 files.

Accepted file formats: .jpg, .jpeg, .png, .pdf, .xls, .xlsx, .csv, .doc, .docx

Shipping Information

Shipping Address Checkbox

Check here if the shipping address is different from the contact address

Shipping Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Terms Checkbox *

By clicking here, I state that I have read and understood the terms and conditions.

Return Policy Checkbox *

By clicking here, I state that I have read and accepted the terms laid out in the Return Policy.

Cleaning Fee Checkbox *

By clicking here, I have consented to a cleaning fee if Precision Medical deems warranted.

Contact Information

Device Information

Shipping Information

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