Service Request

Service request information in advance of sending in your device

Service request information submitted in advance of sending in your device for service skips the line for fast and efficient processing.

Print a copy of your Service Request response email to include in with your device sent in for service. Feel free to add any additional notes or information to the printed email response when sending in your device for service.

Please submit your service request information in advance of sending in your device for service so that when your device is received, it is sent for processing fast and efficiently.
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. The serial number will be 16 digits long.
Type of service requested. Description of what you would like repaired or done.*
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 reported information for service requests. Please advise if the direct use of the device caused a death or serious permanent injury.
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 of owner of Avazzia device to be serviced:*
First Last
Address of owner of Avazzia device to be serviced:*
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.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Organization of device owner
Email address of device owner for sending field safety advisory notices:*

Email addresses provided as part of service or repair requests are maintained on file as contact information for sending product recalls or field safety advisories and notifications as may be needed in the future and copy selections below. Emails are not given, distributed or sold or provided to other entities without direction.
Email address for correspondence related to this service request*
Phone for correspondence related to this service request.*
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*
- Yes, I certify that the information provided is truthful to the best of my knowledge.
- No, I do not certify the information is correct.
The following optional, voluntary information would be appreciated by our research department.
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