Repair Exchange Return

Repair Exchange Return

Depot Repair Request Form
PLEASE SUBMIT ONE FORM FOR ALL SERIAL NUMBERS OF SAME MODEL.
Request Date *

Month Day Year
Model Number *

MA1100-PM MA1200-PM TP700 TP700C
Serial Number(s) *
Please use one form for all serial numbers
For Stryker Air Pump -2861 repairs, contact Stryker Technical Support at 800.327.0770 Option 2. Ask for Dispatch.
SERVICE REQUEST

CONSIGNMENT EXCHANGE - WAIT FOR A REPLACEMENT NO EXCHANGE / END OF USE - A BOX WILL BE SHIPPED TO YOU REQUEST PARTS WARRANTY EXCHANGE - TPUMP ONLY NONCONSIGNED MISTRAL AIR REPAIR $500 CHARGE NONWARRANTY TPUMP REPAIR REPLACEMENT $250 CHARGE - Must be less than 2yrs old
Contact
First Name
Last Name
Phone Number

Area Code Phone Number
E-mail *
Are you a Kenco Logistics Employee?

No Yes
RDC

CHG DAL DEN JAN KZO OAK ORL POR LIV CHO
Shipping and Billing
Your Stryker Customer Number
Ship To
Facility Name
ATTN To
Facility Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Bill To
Same as Ship To above
Facility Name
ATTN To
Facility Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Billable PO for Non-Warranty Units
Date of Incident *

Month Day Year
Date of incident (Kenco only)

Unaware of incident date used current date Actual incident date
Description of Complaint. Please provide details.
*Optional Parts Request for local repair
Refer to Service Manual for availability of parts
Description of Issue (Kenco only)
Stryker Contact Date

Month Day Year
Patient Involvement?

Yes No Unaware
Adverse Outcomes?

Yes No Unaware
If yes, please describe the alleged injury:
Medical Intervention Required?

Yes No Unaware
If yes, please describe, including any unanticipated medical procedures, treatments and or therapy administered in relation to the alleged event:
How was the issue noticed? (ex: cleaning, during or after procedure, upon receipt of new unit, during preventative maintenance) *
How was the issue noticed (Kenco only)
If during procedure, was the procedure completed successfully?

Yes No N/A
Did the issue result in any delay or prolongation to any medical procedure or treatment?

Yes No Unknown
If yes, for how long?
I acknowledge, as part of the repair process, minor non-safety related enhancements may be made to the product.

Yes No
By selecting no, we will not be able to process your repair request.
For questions regarding this form or a repair, please email us at return.repair@stryker.com.
Revision 1.0
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Repair Exchange Return

Contact

Shipping and Billing