Service request information in advance of sending in your device Avazzia device type*What is the name of the Avazzia device to be sent in for service?Device Serial NumberCheck 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. 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 AfghanistanÃ…land IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email address:* This field is hidden when viewing the formEmail 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*Device was purchased for personal use.Device was purchased by a licensed healthcare practitioner for use in practiceWhen did you purchase your device?Approximate date is sufficient. It does not have to be exact. Where did you purchase your device?Choose an optionAvazzia WebsiteHealthcare ProviderDistributorDealerAmazon.comOtherPlease specify the name of the Healthcare Provider, Distributor, Dealer, Representative or WebsiteKeep my distributor or rep updated - Select one*Yes, copy my distributor or rep about this service request to keep them informed.No, do not copy my distributor or rep about this service request.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 formName, company of person completing this form.*Enter "Self" if the same as device owner listed above.CAPTCHA Δ
