Return & Refund Form

If you would like to request a return or refund please fill out the form below.

After submitting the form, please print a copy of the form to include in the shipping box with any returned product.

A member of our team will be in contact with you shortly to provide further instructions if needed.

"*" indicates required fields

Name*

First Last

Address*

Street Address Address Line 2 City State/Province Zip Country

Email*

Phone*

Do you want a return or refund related to a device fault?

Yes

Date of Incident**

Device Type, Size and Quantity*

Northeast Scientific Lot#*

What is the nature of the complaint?

(Please be as specific as possible)

Did the device fault result in a patient impact?

Yes

If so, what type?

Did the device fault occur while the device was inserted into the patient?

Yes