Repair & Exchange Request Form

Request Date *

- Month - Day Year

Model Number *

MA1100-PM MA1200-PM TP700 TP700C

For Stryker Air Pump -2861 repairs, contact Stryker Technical Support 800.327.0770 Option 2 to be connected with your Field Technician

Serial Number(s) Please use one form for all serial numbers *

First Name

Last Name

Phone Number

- Area Code Phone Number

E-mail *

Are you a Kenco Logistics Employee?

No Yes

RDC

Your Stryker Customer Number

Ship To

Facility Name

ATTN To

Facility Address

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

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.

Parts Request for local repair *Optional

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 contact return.repair@stryker.com.

Revision 1.0

Repair & Exchange Request Form

Contact

Shipping and Billing

Event Description