Repair Requisition Form

Today's Date
Full name
Email
Best Phone number to reach you


Address for return of equipment

Business Name
Street Address
Street Address Line 2
City
State/Province
Postal/Zip Code
Country


Billing Address

Business Name
Street Address
Street Address Line 2
City
State/Province
Postal/Zip Code
Country


Payment Method
What needs repaired? (serial # of Acutron or VB must be provided)
Purchase Date
Purchase Date
Describe
Who was the equipment purchased from?
Please describe the malfunction in detail
If you are sending in more than one device describe malfunction of the second one here. Make sure you label what equipment you are writing about here
When did this problem start?
When did you first report it to Eastwestmed?
Precisely describe the sequence of actions that makes the problem happen, so our technicians can re-create it
Is this an intermittent problem that comes and goes?
Please Explain
Are you willing to pay extra for expedited freight to get it to and from the repair center more quickly?
Any other questions or comments about your repair needs?
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“I continue to be astounded by the effectiveness of the Acutron Mentor”
-JanAllen,LAc
(Redondo Beach, CA)
“After becoming familiar your Acutron stimulator, I consider it to be an instrument of the highest order.”                           
- Nguyen Van Nghi, M.D., Director (French Review of Traditional Chinese Medicine, Marseilles, France)
“I've had just phenomenal results with the Acutron Mentor....You can use it for so many applications.”
-Margie Simmons-Stuper, Sports Medicine Therapist, (Mesa, AZ)
Click here for more testimonials and clinical accounts from Acutron Mentor users