LOST INSTRUMENT FORM

LOST INSTRUMENT FORM
Date Lost

MonthDayYear
Date
Replacement Requested

YesNo
Replacement by (date)

MonthDayYear
Date
REQUESTOR
Name*

First NameLast Name
Hospital lost at
Distributor/Territory Manager
SHIPPING ADDRESS
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
INSTRUMENT LOST
Instrument Part Number
Instrument Description
Notes
Who will pay for this part?

HospitalDistributorship
Fees

All lost instruments are charged at list price for hospitals, or 50% off list price for Distributors and Territory Managers. PO’s for lost instruments must be turned in within thirty (30) days of date lost or Territory Manager/Distributor will be responsible for cost. If instrument is found, replacement instrument ships back to TJO within seven (7) days or a $100 fee will be charged.
TOTAL JOINT ORTHOPEDICS

MISSION-DRIVEN™

1567 East Stratford Ave.
Salt Lake City, Utah 84106
o. 888.890.0102 f. 801.486.6117 sales@tjoinc.com
Should be Empty:

REQUESTOR