Drive Oxygen Concentrator RMA Request Form

Model Number(Required)

Please enter the model number

Serial Number(Required)

Please enter the device serial number

Hours(Required)

Please upload photo of hour meter

Drop files here or

Accepted file types: jpg, png, bmp, gif, pdf, Max. file size: 64 MB.

Were any off-brand filters being used?(Required)

(Select "Yes" if any non-Drive filters were used)

Description of the defect or reason for return:(Required)

Was there an injury?(Required)

Did the user seek medical attention?(Required)

Resolution (Do you need parts, replacement, credit, etc.?):(Required)

Business Name:

Contact Name and information:

Your Email Address(Required)

Please enter your email address

Enter Email Confirm Email

Your Phone Number(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Attach photo/s of the defect/damage:(Required)

Drop files here or

Accepted file types: jpg, png, pdf, bmp, gif, Max. file size: 64 MB.

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