Product Incident Report Form

	Americas
	Hygiena 941 Avenida Acaso Camarillo, CA USA 93012 Tel: +1 805.388.8007 x.300 Fax: +1 805.388.5531 info@hygienausa.com Europe, Middle East, Africa & Asia Hygiena International Unit 11 WENTA Business Centre Colne Way, Watford, Hertfordshire WD24 7 ND. UK +44 (0)1923 818821 (tel) +44 (0)1923 818825 (fax) enquiries@hygiena.net

Product Incident Report Form - SystemSURE

*Serial Number:

Date of Purchase:

*Company:

*Contact Person:

*Phone:

*Email:

*Street Address:
(where repaired instrument will be sent)

*City/Town:

*State/Province:

*Zip/Postal Code:

*Country:

Name of Distributor:
(if applicable)

*Description of problem:

Under Warranty

Yes No

(1 Year from date of purchase. If you are unsure select "No".
If it is under warranty, we will not charge you for repairs )

Would you like a
temporary replacement
while your instrument
is being repaired?

Yes No

(Temporary replacements cost $50.00 + Shipping for instruments not under warranty.)

Payment Options
The cost associated with a repair, temporary instrument and shipping can
be put on a Purchase Order or Credit Card. Please Select the payment
option you would like to use:
Purchase Order Credit Card

(You will get a call from a Hygiena customer service representative requesting credit card information if the credit card option is selected.)

Only fill if paying by P.O.#

P.O. #: (To cover shipping costs associated with sending temporary instrument)

P.O. #: (To cover repair costs of instrument if not under warranty)

Shipping Collect Account Number: (if applicable)

** All repair requests for instruments "not under warranty" are subject to a nonrefundable $50 evaluation fee. Once the instrument is evaluated, this fee will be applied towards the cost of any required instrument repairs. Customers having instruments repaired under or not under warranty are responsible for the return of the temporary replacement and the associated shipping costs. Customers are responsible for the shipping costs of the damaged instrument to Hygiena.

** Please note: Not all damages are covered by warranty; damage from improper handling of the instrument will incur charges. In addition, the warranty expires after one year, unless otherwise extended by Hygiena.

** Repair Charges: Hygiena will email you the repair cost before the repair process begins for approval. Not to exceed $550.00. In the event of irreparable damage, a new unit may be purchased for $750.00 or a refurbished system for $650.00 if a refurbished instrument is available in stock. You will be billed for any charges directly through Hygiena.