Service request
Date of equipment service request
*
-
Month
-
Day
Year
Date
Client /Primary user name
*
First Name
Middle Name
Last Name
Primary user phone number or responsible party
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of person returning equipment:
*
First Name
Last Name
Address of person returning equipment for service:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address where serviced equipment should be returned:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number of person returning equipment:
*
Format: (000) 000-0000.
Email for return instructions:
*
example@example.com
Equipment returned
*
OxyGo NEXT
Precision Medical Live Active 5
OxyGo FIT
OxyGo
Inogen One G5
Inogen One G3
Inogen One G4
GCE Zen-O
O2 Concepts Oxlife Independence
Nidek 10
3B Medical Stratus 5
Caire Eclipse
Caire Airsep Intensity
Nidek Lite
Serial Number (use separate "Equipment Service Request " for additional equipment needing service)
*
Service Request:
*
Purchased Equipment Needs Service
Will you need a loaner while your equipment is in for service?
*
No
Yes
All equipment will be returned to factory for service unless specified by factory. Equipment serviced by factory can take several weeks and do not have a return date specified.
*
Acknowledgement of factory repair time frames and loaner options.
Not responsible for accessories. Do not return batteries, bags cables or any accessories with equipment needing service (portable concentrator only or stationary)
*
I am only sending the portable oxygen concentrator(remove battery and carry bag)
Stationary oxygen concentrator(no humidifiers or nasal cannulas)
How I'm returning equipment
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I will take the equipment to Common Carrier UPS, FedEx (recommended for proper packaging)
Request courier(local pick up only, charges apply)
Getting loaner, will return with loaner packaging(return label inside loaner packaging, charges apply)
Other schedule appointment (contact office)
Returning your equipment will require a service order number. Instructions with order number will be emailed to you after request has been submitted
*
I agree to all the terms and conditions of Oxygen Parts Inc.
Client signature
*
Submit
Should be Empty: