subject_line
Return Authorization Request Form
What type of item(s) are you returning?
*
Shoes
All Other Items
If a shoe is listed, will the manufacturer insert be included with the shoe when returned?
*
Yes
No
NA
Date
*
+
Name
*
Phone Number
*
Email Address
*
Company Name
*
Account Number
*
Return Authorization Policy | Shoes - Requested within 60 days of invoice date | All Other Items - Requested within 60 days of invoice date | Non-stock - Varies by supplier
1. Order #
*
PO #
*
Product #
*
QTY
*
Patient ID
Reason
*
1a. Patient Rejected - used
1b. Patient Rejected - unused
2. Patient Cancelled
3. Ordered Wrong
4. CSR/Shipping Error
5. Multiple Sizes Ordered
6. Sizing Chart Incorrect
7. Substituted Item
8a. Defective - Out of Box
8b. Defective - Premature Wear
8c. Defective - Product Failure
9. Warranty
10. Other (explain)
Is the product packaging opened or sealed?
*
Opened
Sealed
Defective Explanation
*
Detailed Explanation
*
Add as much necessary information to your warranty return/exchange to avoid delays.
Cause of Failure
*
Original Serial #
Replacement Serial #
Replacement PO #
Items under warranty may require warranty cards, replacement serial numbers, or patient information before credit can be issued.
Click here to view warranty forms
.
ATTN: Warranty forms & cards are REQUIRED before an RA # can be issued.
Attach a copy of warranty card included with original shipment and/or warranty form from the above link if required.
Fit Date
+
Failed Date
+
2. Order #
PO #
Product #
QTY
Patient ID
Reason
1a. Patient Rejected - used
1b. Patient Rejected - unused
2. Patient Cancelled
3. Ordered Wrong
4. CSR/Shipping Error
5. Multiple Sizes Ordered
6. Sizing Chart Incorrect
7. Substituted Item
8a. Defective - Out of Box
8b. Defective - Premature Wear
8c. Defective - Product Failure
9. Warranty
10. Other (explain)
Is the product packaging opened or sealed?
Opened
Sealed
Defective Explanation
*
Detailed Explanation
*
Add as much necessary information to your warranty return/exchange to avoid delays.
Cause of Failure
*
Original Serial #
Replacement Serial #
Replacement PO #
Items under warranty may require warranty cards, replacement serial numbers, or patient information before credit can be issued.
Click here to view warranty forms
.
ATTN: Warranty forms & cards are REQUIRED before an RA # can be issued.
Attach a copy of warranty card included with original shipment and/or warranty form from the above link if required.
Fit Date
+
Failed Date
+
3. Order #
PO #
Product #
QTY
Patient ID
Reason
1a. Patient Rejected - used
1b. Patient Rejected - unused
2. Patient Cancelled
3. Ordered Wrong
4. CSR/Shipping Error
5. Multiple Sizes Ordered
6. Sizing Chart Incorrect
7. Substituted Item
8a. Defective - Out of Box
8b. Defective - Premature Wear
8c. Defective - Product Failure
9. Warranty
10. Other (explain)
Is the product packaging opened or sealed?
Opened
Sealed
Defective Explanation
*
Detailed Explanation
*
Add as much necessary information to your warranty return/exchange to avoid delays.
Cause of Failure
*
Original Serial #
Replacement Serial #
Replacement PO #
Items under warranty may require warranty cards, replacement serial numbers, or patient information before credit can be issued.
Click here to view warranty forms
.
ATTN: Warranty forms & cards are REQUIRED before an RA # can be issued.
Attach a copy of warranty card included with original shipment and/or warranty form from the above link if required.
Fit Date
+
Failed Date
+
4. Order #
PO #
Product #
QTY
Patient ID
Reason
1a. Patient Rejected - used
1b. Patient Rejected - unused
2. Patient Cancelled
3. Ordered Wrong
4. CSR/Shipping Error
5. Multiple Sizes Ordered
6. Sizing Chart Incorrect
7. Substituted Item
8a. Defective - Out of Box
8b. Defective - Premature Wear
8c. Defective - Product Failure
9. Warranty
10. Other (explain)
Is the product packaging opened or sealed?
Opened
Sealed
Defective Explanation
*
Detailed Explanation
*
Add as much necessary information to your warranty return/exchange to avoid delays.
Cause of Failure
*
Original Serial #
Replacement Serial #
Replacement PO #
Items under warranty may require warranty cards, replacement serial numbers, or patient information before credit can be issued.
Click here to view warranty forms
.
ATTN: Warranty forms & cards are REQUIRED before an RA # can be issued.
Attach a copy of warranty card included with original shipment and/or warranty form from the above link if required.
Fit Date
+
Failed Date
+
5. Order #
PO #
Product #
QTY
Patient ID
Reason
1a. Patient Rejected - used
1b. Patient Rejected - unused
2. Patient Cancelled
3. Ordered Wrong
4. CSR/Shipping Error
5. Multiple Sizes Ordered
6. Sizing Chart Incorrect
7. Substituted Item
8a. Defective - Out of Box
8b. Defective - Premature Wear
8c. Defective - Product Failure
9. Warranty
10. Other (explain)
Is the product packaging opened or sealed?
Opened
Sealed
Defective Explanation
*
Detailed Explanation
*
Add as much necessary information to your warranty return/exchange to avoid delays.
Cause of Failure
*
Original Serial #
Replacement Serial #
Replacement PO #
Items under warranty may require warranty cards, replacement serial numbers, or patient information before credit can be issued.
Click here to view warranty forms
.
ATTN: Warranty forms & cards are REQUIRED before an RA # can be issued.
Attach a copy of warranty card included with original shipment and/or warranty form from the above link if required.
Fit Date
+
Failed Date
+
6. Order #
PO #
Product #
QTY
Patient ID
Reason
1a. Patient Rejected - used
1b. Patient Rejected - unused
2. Patient Cancelled
3. Ordered Wrong
4. CSR/Shipping Error
5. Multiple Sizes Ordered
6. Sizing Chart Incorrect
7. Substituted Item
8a. Defective - Out of Box
8b. Defective - Premature Wear
8c. Defective - Product Failure
9. Warranty
10. Other (explain)
Is the product packaging opened or sealed?
Opened
Sealed
Defective Explanation
*
Detailed Explanation
*
Add as much necessary information to your warranty return/exchange to avoid delays.
Cause of Failure
*
Original Serial #
Replacement Serial #
Replacement PO #
Items under warranty may require warranty cards, replacement serial numbers, or patient information before credit can be issued.
Click here to view warranty forms
.
ATTN: Warranty forms & cards are REQUIRED before an RA # can be issued.
Attach a copy of warranty card included with original shipment and/or warranty form from the above link if required.
Fit Date
+
Failed Date
+
7. Order #
PO #
Product #
QTY
Patient ID
Reason
1a. Patient Rejected - used
1b. Patient Rejected - unused
2. Patient Cancelled
3. Ordered Wrong
4. CSR/Shipping Error
5. Multiple Sizes Ordered
6. Sizing Chart Incorrect
7. Substituted Item
8a. Defective - Out of Box
8b. Defective - Premature Wear
8c. Defective - Product Failure
9. Warranty
10. Other (explain)
Is the product packaging opened or sealed?
Opened
Sealed
Defective Explanation
*
Detailed Explanation
*
Add as much necessary information to your warranty return/exchange to avoid delays.
Cause of Failure
*
Original Serial #
Replacement Serial #
Replacement PO #
Items under warranty may require warranty cards, replacement serial numbers, or patient information before credit can be issued.
Click here to view warranty forms
.
ATTN: Warranty forms & cards are REQUIRED before an RA # can be issued.
Attach a copy of warranty card included with original shipment and/or warranty form from the above link if required.
Fit Date
+
Failed Date
+
8. Order #
PO #
Product #
QTY
Patient ID
Reason
1a. Patient Rejected - used
1b. Patient Rejected - unused
2. Patient Cancelled
3. Ordered Wrong
4. CSR/Shipping Error
5. Multiple Sizes Ordered
6. Sizing Chart Incorrect
7. Substituted Item
8a. Defective - Out of Box
8b. Defective - Premature Wear
8c. Defective - Product Failure
9. Warranty
10. Other (explain)
Is the product packaging opened or sealed?
Opened
Sealed
Defective Explanation
*
Detailed Explanation
*
Add as much necessary information to your warranty return/exchange to avoid delays.
Cause of Failure
*
Original Serial #
Replacement Serial #
Replacement PO #
Items under warranty may require warranty cards, replacement serial numbers, or patient information before credit can be issued.
Click here to view warranty forms
.
ATTN: Warranty forms & cards are REQUIRED before an RA # can be issued.
Attach a copy of warranty card included with original shipment and/or warranty form from the above link if required.
Fit Date
+
Failed Date
+
Return product(s) to SPS within 15 days of receiving RA #
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