RGA
(833) 423-3786
Welcome to the new Adepto Medical RGA Form!
Thank you for your continued business, we hope the new features make your visit more enjoyable!
Create RGA
* Required
RGA Type
*
Select Type
Rental Return
Service
Warranty / Malfunctions
Fill out the form below to receive a free shipping label.
#
Model Name
SN
RGA Reason
Additional notes for device
(Version, Clear Drug Library, ect...)
1
Return
General Service
P.M. / Re-certified
Cosmetic damage
Error code
Unknown Issue
Fluid intrusion
PATIENT INCIDENT
2
Return
General Service
P.M. / Re-certified
Cosmetic damage
Error code
Unknown Issue
Fluid intrusion
PATIENT INCIDENT
3
Return
General Service
P.M. / Re-certified
Cosmetic damage
Error code
Unknown Issue
Fluid intrusion
PATIENT INCIDENT
4
Return
General Service
P.M. / Re-certified
Cosmetic damage
Error code
Unknown Issue
Fluid intrusion
PATIENT INCIDENT
5
Return
General Service
P.M. / Re-certified
Cosmetic damage
Error code
Unknown Issue
Fluid intrusion
PATIENT INCIDENT
6
Return
General Service
P.M. / Re-certified
Cosmetic damage
Error code
Unknown Issue
Fluid intrusion
PATIENT INCIDENT
7
Return
General Service
P.M. / Re-certified
Cosmetic damage
Error code
Unknown Issue
Fluid intrusion
PATIENT INCIDENT
8
Return
General Service
P.M. / Re-certified
Cosmetic damage
Error code
Unknown Issue
Fluid intrusion
PATIENT INCIDENT
9
Return
General Service
P.M. / Re-certified
Cosmetic damage
Error code
Unknown Issue
Fluid intrusion
PATIENT INCIDENT
10
Return
General Service
P.M. / Re-certified
Cosmetic damage
Error code
Unknown Issue
Fluid intrusion
PATIENT INCIDENT
Company Contact
Company
*
Phone number
Email
*
First name
Last name
PO
Pre-approved Cost
$
Do you need a free shipping label?
*
Select an Option
No Label
1
2
3
4
5
Request local LA/KC pickup instead?
No
Yes (Pre-authorized customers only)
Ship as Blind
No
Yes
Ship From Address
Address
*
Address 2
City
*
State
*
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
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Kansas
Kentucky
Louisiana
Maine
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Pennsylvania
Rhode Island
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South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Zip
*
Country
*
Select Country
United States
Mexico
Canada
Return Address
(After Service)
Please leave blank if same as 'Ship From' address
Address
Address 2
City
State
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Zip
Country
Select Country
United States
Mexico
Canada
Billing Address
Please leave blank if same as 'Ship From' address
Address
Address 2
City
State
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Zip
Country
Select Country
United States
Mexico
Canada