Repair / L&D Warranty Claim Form
Please provide details about the loss or damage and your warranty information.
Patient Name
*
First Name
Last Name
PO #:
*
Warranty End Date
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Audiologist Name
*
First Name
Last Name
Product Model
*
Serial Numbers
Date of device sent in / L&D claim
*
-
Month
-
Day
Year
Date
Why are you making a claim?
Option 1
Option 2
Option 3
I certify that this is an in warranty claim and no additional charges will accrue. I understand that my clinic is responsible for any additional charges.
*
Option 1
Option 2
Option 3
Patient Name
*
First Name
Last Name
PO #:
*
Warranty End Date
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Audiologist Name
*
First Name
Last Name
Product Model
*
Serial Numbers
Date of device sent in / L&D claim
*
-
Month
-
Day
Year
Date
Why are you making a claim?
Loss
Damage beyond repair
Repair
Other
I certify that this is an in warranty claim and no additional charges will accrue. I understand that my clinic is responsible for any additional charges.
*
Yes
No
Submit Claim
Should be Empty: