MohawkMedicalMall.com
Product Return Form

Account #
(From Packing Slip)
Order #
(From Packing Slip)
Invoice # 		__________

__________

__________ 		Return Authorization Number __________
(From Customer Service( 800 ) 962-5660)

Product Code Quantity Product Description Return
Code
    Return Codes*
  1. Wrong Item Shipped
  2. Did not Order Item
  3. Over Shipped
  4. Wrong Item Ordered
  5. Item Not As Expected
  6. Defective Product
  7. _________________













Please Credit My Account: _______
OR
Please Exchange For The Following Product(s):
Product Code Quantity Product Description Unit Price ExtendedPrice

















Please use this space for comments. Your feedback is appreciated.
______________________________________________________________

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For Mohawk Use. Please do not write in this box
Date Item(s) Picked Up Via UPS Call Tag: __________
Date Item(s) Are Returned By Customer: __________


Return To: Mohawk Medical Mall Returns
Mohawk Hospital Equipment, Inc.
335 Columbia Street
Utica, New York 13502