Return Merchandise Authorization (RMA) Form

RMA Request

Please fill out the form below to request a Return Merchandise Authorization (RMA) number.

You will be notified via email within 2 business days of your RMA acceptance and RMA Number.


All fields must be filled out properly for RMA consideration.

Billing/Ownership Information
Name:
Title:
Medical/Surgical Specialty:
Facility Name:
Facility Address:
 
City, State Zip:   ,   
Country:
Phone:
Fax:
Contact E-Mail:






Ship to address (if different from above):
Name:
Company:
Address:
 
City, State Zip:   ,   
Country:






Pump Information:
Model Name/Number:
Serial Number:
Loaner pump requested?   Yes      No
Patient Injury:   Yes      No
Reason for RMA Request:
Please be specific: ie.
Alarm number showing on screen
If damaged give description
PM - Periodic Maintenance
Terms of use © 2008 Curlin Medical Inc., a subsidiary of Moog Inc. All rights reserved.
15751 Graham Street | Huntington Beach, California 92649-1630
Phone: 714.893.2200 | Fax: 714.894.2602 | Email: info@CurlinMedical.com.
Curlin Medical