Repair & Exchange Request Form

Request Date *

- Month - Day Year

Date Picker Icon

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 Picker Icon

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

Date Picker Icon

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