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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*
First Beneficiary Date of Birth*
First Beneficiary Signature*
Second Beneficiary Name

First Name*

Middle Name

Last Name*
Second Beneficiary Date of Birth*
Third Beneficiary Name

First Name*

Middle Name

Last Name*
Third Beneficiary Date of Birth*
Fourth Beneficiary Name

First Name*

Middle Name

Last Name*
Fourth Beneficiary Date of Birth*
Fifth Beneficiary Name

First Name*

Middle Name

Last Name*
Fifth Beneficiary Date of Birth*
Sixth Beneficiary Name

First Name*

Middle Name

Last Name*
Sixth Beneficiary Date of Birth*
Seventh Beneficiary Name

First Name*

Middle Name

Last Name*
Seventh Beneficiary Date of Birth*
Eighth Beneficiary Name

First Name*

Middle Name

Last Name*
Eighth Beneficiary Date of Birth*
Ninth Beneficiary Name

First Name*

Middle Name

Last Name*
Ninth Beneficiary Date of Birth*
Tenth Beneficiary Name

First Name*

Middle Name

Last Name*
Tenth Beneficiary 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*
Parent or Guardian's 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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