Return Goods Authorization (RGA) Request Form

Contact Information

Name

First

Last

Company

Phone

Email

Additional Email

Add an additional email to be copied on the confirmation email.

Servicing Email Shipping

Address

Address Line 1

Address Line 2

City

State

Zip Code

Device Information

When you have multiple devices, upload a file listing the model and/or serial numbers and the corresponding issues. If uploading a file, enter See attachment for the required fields Model Numbers(s) and Issue.

Provide images if the device arrived damaged.

You can also upload images to help show the issue with your device.

Model Number(s)

Serial Number(s)

Issue

File Upload

Click or drag files to this area to upload. You can upload up to 10 files.

Allowed file formats: .jpg, .jpeg, .png, .pdf, .xls, .xlsx, .csv, .doc, .docx

Manufacturer’s Servicing Fee

I consent to a manufacturer's servicing fee if DRW Medical deems warranted.

Shipping Information

My shipping address is different from the contact address.

Attention: