USMS RMA Form

Date *

Facility Name *

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Department *

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Contact Name *

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Contact Phone Number *

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Contact Email *

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Confirm Contact Email *

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Street Address *

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City *

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State *

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Zip Code *

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Purchase Order Number *

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Please Check the Box to Request a Shipping Label *

Yes
No

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Quantity (Item 1) *

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Enter Manufacturer, Model, Serial Number, and Description of Issue (Item 1) *

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Quantity (Item 2)

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Enter Manufacturer, Model, Serial Number, and Description of Issue (Item 2)

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Quantity (Item 3)

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Enter Manufacturer, Model, Serial Number, and Description of Issue (Item 3)

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Quantity (Item 4)

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Enter Manufacturer, Model, Serial Number, and Description of Issue (Item 4)

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Quantity (Item 5)

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Enter Manufacturer, Model, Serial Number, and Description of Issue (Item 5)

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Get updates, alerts and special offers from US Medical Systems *

Yes, keep me ahead of the curve by informing me of the latest news and offers related to our medical equipment.
No, I'm not interested in staying informed on the latest news and offers related to our medical equipment.

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US Medical Systems

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Contact Information

Equipment Needing Repair