RGA Request Form - American Optisurgical Inc. - Toll Free: 800.576.1266 - Providing Specialized Opthalmic Products and Services

RGA REQUEST FORM

TO REQUEST A RGA (RETURN GOODS AUTHORIZATION) NUMBER, PLEASE COMPLETE THIS FORM. WHEN FINISHED, CLICK "SUBMIT" AT THE BOTTOM OF THIS PAGE.
AOI WILL THEN REPLY TO THE EMAIL ADDRESS YOU PROVIDE ALONG WITH THE RGA NUMBER FOR YOUR SUBMITTED ITEM(S).
PLEASE LIST THE RGA NUMBER(S) ON THE PACKING LIST, AIR WAYBILL, OR ANY OTHER DOCUMENTATION THAT ACCOMPANIES YOUR SHIPMENT.
AN RGA NUMBER IS REQUIRED FOR EACH INSTRUMENT TO BE SENT.

NOTE: MANDATORY FIELDS ARE DENOTED WITH

INFORMATION ABOUT YOU

Your Name:
Company Name:
Address:


City:
State/Province:
Country:
Email:
Telephone:
Fax:

Has AOI repaired an item for you before? : YES NO

ITEM #1 - INFORMATION ABOUT THE INSTRUMENT TO BE SERVICED

Brand or Make: (i.e.: Alcon, Storz)
Model: (i.e.: Legacy, Millennium)
Serial Number:
Problem Experienced: (i.e., will not tune with phaco unit, stuck tip)

Check here if problem is unknown and item needs to be evaluated.

ITEM #2 - INFORMATION ABOUT THE INSTRUMENT TO BE SERVICED

Brand or Make: (i.e.: Alcon, Storz)
Model: (i.e.: Legacy, Millennium)
Serial Number:
Problem Experienced: (i.e., will not tune with phaco unit, stuck tip)

Check here if problem is unknown and item needs to be evaluated.

ITEM #3 - INFORMATION ABOUT THE INSTRUMENT TO BE SERVICED

Brand or Make: (i.e.: Alcon, Storz)
Model: (i.e.: Legacy, Millennium)
Serial Number:
Problem Experienced: (i.e., will not tune with phaco unit, stuck tip)

Check here if problem is unknown and item needs to be evaluated.

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