RETURN FOR CREDIT FORM For faster service, please complete your return for credit request online at www.widexpro.com.
Account #: _______________ Company Name:_______________________ Ship To #: ____________________________________Date:___________ Address:_____________________________________________________ Address: _____________________________________________________ City: _____________________________ State:________ Zip:___________ City: _____________________________ State:________ Zip:___________ P.O. #:_______________________________________________________ Clinician Phone #:______________________________________________ Clinician Name:________________________________________________ Clinician Email:________________________________________________ Patient First Name:_____________________________________________ Patient Last Name:_____________________________________________
Right Serial #:_________________________________________________ Left Serial #:__________________________________________________ Model #:_____________________________________________________ Model #:_____________________________________________________ REMOTE/DEX accessory/TV PLAY Serial #:___________________________ REMOTE/DEX accessory/TV PLAY Serial #:___________________________ REMOTE/DEX accessory/TV PLAY Serial #:___________________________ REMOTE/DEX accessory/TV PLAY Serial #:___________________________
PLEASE SELECT REASON FOR RETURN BELOW Quality Issue
Exchange
2.4 GHz Connectivity
Financial Decision
Will Not Program
iPhone®
Patient Illness/Death
Poor Fit
Pairing Issues
Stock Return
Feedback
App Connection Issues
Patient Changed Mind
Mechanical Failure
Streaming Issues
Return for Credit to Dispense Competitor Product
Android™
Will not stream Intermittent streaming
RETURN POLICY (for all models) Up to 90 days after invoice date . . . . . . . . . . . . . . . . . . . . . . . . . . . Full Credit No returns will be accepted after 90 days from invoice date.
mRIC R D, RIC 10, RIC 312 D, FUSION, FUSION2, and PASSION hearing instruments must be returned with earwire and receiver to receive full credit. Subject to fees if items are missing. See Price & Policy Guide for price information.
Additional Comments: ____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________
Submit to: Widex USA, Inc., 185 Commerce Drive, Hauppauge, NY 11788 Attn: Customer Care Fax: 718.482.1884 Email to: customerservice@widexusa.com Phone: 1.800.221.0188