Pisces Healthcare Solutions. National Contract M3 QRT Wheelchair Warranty Claim

NAME: *

VAMC: *

PHONE: *

EMAIL: *

PO (If known):

MODEL NUMBER (Located on the frame of the wheelchair): *

SERIAL NUMBER (Located on the frame of the wheelchair): *

IF A REPLACMENT CHAIR OR PART IS SHIPPED, PLEASE PROVIDE SHIP TO ADDRESS:

NAME: *

ATTENTION TO: *

STREET: *

CITY: *

STATE: *

ZIP: *

Description of the defect or reason for return: *

ALLOW MULTIPLE FILES OR IMAGES TO BE UPLOADED/ATTACHED:

WARRANTY QUESTIONS:

WAS THERE AN INJURY?:

Yes

No

IF SO, EXPLAIN THE INJURY AND DID THEY RECEIVE MEDICAL TREATMENT:

WAS THE BOX DAMAGED AND IN POOR CONDITION?:

Yes

No

WAS THE PRODUCT DAMAGE FROM SHIPPING/TRANSIT:

Yes

No

PLEASE UPLOAD AVAILABLE PHOTOS OF THE DAMAGE TO THE BOX OR SHIPPING CONTAINER:

WAS THE PRODUCT BROKEN, DAMAGED OR DEFORMED OUT OF THE BOX THAT DID NOT APPEAR TO COME FROM SHIPPING?:

Yes

No

IS THE DAMAGE DUE TO NORMAL WEAR AND TEAR TO THE WHEELCHAIR? EXAMPLE: SEAT CUSHION, WHEELS, CASTERS AND BRAKES?:

Yes

No

ANY ADDITIONAL COMMENTS ABOUT THE WARRANTY CLAIM.:

Pisces Healthcare Solutions will report this warranty claim to the manufacturer. The resolution of this form could result in sending a replacement part, a replacement chair or in the form of a credit to purchase order's Government purchase card. We will process this information and will be contacting you via Email or teleophone to inform you of the resolution of the warranty claim.: