Customer Recall Response Form
Did you receive a recall notice containing a recall code?
Yes
No
Recall Code
*
7 digit number
First and Last Name Stated on Notification
*
First Name
Last Name
Title
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Have you received, read and understood the field safety notice?
*
Yes
No
Do you need a safety instruction label for your Medline brand bed?
*
Yes
No
How many safety labels do you require?
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Questions
Submitted By
First Name
Last Name
By submitting this form you are verifying that you have received, read, understood and performed any actions specified in the recall letter.
Submit
Should be Empty: