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EQUIPMENT WARRANTY INFORMATION FORM

Ramsey Dental

5110 Park Rd, suite 2a

Charlotte NC 28205

 

 

 

Every product sold or rented by our company carries a 1-year manufacturer’s warranty.

Ramsey Dental will notify all Medicare beneficiaries of the warranty coverage and we will honor all warranties under applicable law.

Ramsey Dental will repair or replace, free of charge, Medicare-covered equipment that is under warranty.  In addition, an owner’s manual with warranty information will be provided to beneficiaries for all durable medical equipment where this manual is available.

I have been instructed and understand the warranty coverage on the product I have

received.

First Beneficiary Name
First Name*
Middle Name
Last Name*
Select Gender
First Beneficiary Date of Birth*
Date of Birth
First Beneficiary Signature*
Second Beneficiary Name
First Name*
Middle Name
Last Name*
Select Gender
Beneficiary Date of Birth*
Date of Birth
Third Beneficiary Name
First Name*
Middle Name
Last Name*
Select Gender
Beneficiary Date of Birth*
Date of Birth
Fourth Beneficiary Name
First Name*
Middle Name
Last Name*
Select Gender
Beneficiary Date of Birth*
Date of Birth
Fifth Beneficiary Name
First Name*
Middle Name
Last Name*
Select Gender
Beneficiary Date of Birth*
Date of Birth
Sixth Beneficiary Name
First Name*
Middle Name
Last Name*
Select Gender
Beneficiary Date of Birth*
Date of Birth
Seventh Beneficiary Name
First Name*
Middle Name
Last Name*
Select Gender
Beneficiary Date of Birth*
Date of Birth
Eighth Beneficiary Name
First Name*
Middle Name
Last Name*
Select Gender
Beneficiary Date of Birth*
Date of Birth
Ninth Beneficiary Name
First Name*
Middle Name
Last Name*
Select Gender
Beneficiary Date of Birth*
Date of Birth
Tenth Beneficiary Name
First Name*
Middle Name
Last Name*
Select Gender
Beneficiary Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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