Service Request

Service request information in advance of sending in your device

Print a copy of your Service Request response email and include it with your device when you send it in for service. Include any additional helpful notes or information.

Avazzia device type*
What is the name of the Avazzia device to be sent in for service?
Device Serial Number
Check inside the battery compartment of the device, by removing the batteries. The serial number will be 17 digits long.
Type of service requested. What needs to be addressed with your device?*
Please include description for service to be able to reproduce reported problems to be serviced. Please include name of distributor or rep or anyone authorized to discuss this service request.
Death or injury: Check One*
International Medical device regulatory authorities require safety information reported for service requests Was there a death or serious permanent injury requiring emergency or hospital care?
- Yes
- No
US FDA regulations require medical device owner name and contact information to be filed with medical device service repair records. This information may be reviewed by the US FDA upon request.
Full Name and address of owner of Avazzia device to be serviced:*
First Last
Address of owner of Avazzia device to be serviced:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email address:*
This field is hidden when viewing the form
Email address for correspondence related to this service request*
Phone for correspondence related to this service request.*
Organization of device owner, or "self"
Contact information is confidential and will only be used for this service request. It will be maintained on file only for sending product recalls or field safety advisories and notifications.
Professional or personal use - select one*
When did you purchase your device?
Approximate date is sufficient. It does not have to be exact.
MM slash DD slash YYYY
Where did you purchase your device?
Please specify the name of the Healthcare Provider, Distributor, Dealer, Representative or Website
Keep my distributor or rep updated - Select one*
Return shipping name and address if different from owner above:
Certification of truthfulness*
- I certify that the information provided is truthful to the best of my knowledge.
The following optional, voluntary information would be appreciated by our research department.
This field is hidden when viewing the form
Name, company of person completing this form.*
Enter "Self" if the same as device owner listed above.
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Service request information in advance of sending in your device

CONTACT US

Avazzia, Inc.

Clinical Research Request