Housing Credit Request

Please read instructions
1. An RA number is required for Housing Credit.
2. Please use this form for HOUSING CREDITS ONLY.
3. Complete and e-mail this form by clicking Submit or Print and Fax
to 843 760 0079. We will contact you with an RA number, and shipping instructions.
4. Mark the shipping container and paperwork with the RA number.
5. Please insure that all housings are cleaned of blood, contrast media and any body fluid residue, before returning.
6. Ship the failed housing to the address indicated with the RA number.
7. Customer assumes responsibility for freight charges and any damage that may occur during shipping.

	* Required fields
* Dealer Name
* Date
Address
* Phone
Fax
OR
* E-mail
* Tube type	Diagnostic
	CT
Installed Date
Removed Date
Slices (CT Only)
* Returned tube serial number	(e.g. 12345-1A)
* Replacement tube serial number	(e.g. 12345-1A)
OR
Replacement tube Sales / Invoice / Dealer PO Number
How should the Credit be paid	Account Credit
	Refund Payment
	Bank Transfer (provide bank details below)
Special Instructions