Power Cord Replacement Form

Arizant Healthcare Inc.
Power Cord Replacement Form
If you are experiencing difficulties accessing your account, please call
1-877-947-1487.

*required fields

Customer Number* (located on letter)

Five Digit Zip Code*
(located on letter)

Unauthorized use of or access to this site is prohibited. Actual or attempted unauthorized use of or access to this site may result in criminal and/or civil prosecution.

During your Arizant product inspection, did you discover any damaged cords?*

Yes

No

If yes, how many?

To expedite follow-up, please take a moment to establish a primary and secondary contact.

Primary Contact

First Name*		Last Name*
Title*
Phone*
Email*		Confirm Email*

Preferred method of contact? by phone by email

Secondary Contact

First Name		Last Name
Title
Phone
Email		Confirm Email

Preferred method of contact? by phone by email

Requested Action

Please contact me

Please send my cord(s)

No Charge PO# (optional)

To the attention of*

Contact information collected will be used only for the purposes of this power cord recall.

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