⚠ Clean Certified

This form must be completed and submitted to us prior to returning any instruments and/or devices, regardless of actual usage.

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RGA (Return Goods Authorization) Form
Purpose of this RGA
Select all that apply. A RGA number is issued only for these four reasons.
Used to build your RGA number. We suggest initials from the facility name; correct them if your facility uses different ones (letters and numbers only, up to 8).
Facility Address
Facility Address
City
State/Province
Zip/Postal
The RGA confirmation and PDF are sent to this address.
One instrument per line: catalog number, serial number, quantity. Example: 52-305-02SPFB, SN 12345, qty 1
Repairs are not performed until a valid purchase order number is provided. Once we receive and assess the instruments we will send an estimate for the work.

Maximum file size: 10MB

Upload up to 6 photos showing the damage or issue. Photos are automatically reduced in size after upload.
We hereby CERTIFY that the instruments listed above have been cleaned and sterilized prior to shipping according to the following guidelines. Check all that apply:
Instrument Use Status (non-use certification)
The person signing below.
Examples: Sterile Processing Manager, OR Manager, Materials Manager.
Electronic Signature Acknowledgment
Sign with your mouse, trackpad, or finger.

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Obtain a Return Authorization Number by completing this form.  When received, we will return this form with an assigned RMA No.  Once you receive the Return Authorization Number from us, please place it in a packing slip pouch.  Please attach to the outside of the carton, making sure the “RMA” number can be seen through the pouch.  Any packages that are received without a completed form are subject to refusal or a predetermined $900.00 cleaning fee.  Any instrument that comes back contaminated and not cleaned will be immediately disposed.  In case of additional questions or concerns, please call us at (800) 497-0851.

Please email us the Shipping tracking information to expedite your package.