SMGH

First Name*

Last Name*

Email Address*

Phone Number*

Date of Birth*

Home Address*

Patient's Phone Number

Name of Contact Person

What did you report?*

Damage

missing lost item

What is damaged or missing/lost? (please keep damaged items and show them on request)*

Did another party pay for the item?*

Yes

No

Do you have a proof of purchase receipt?*

Yes

No

Has the damaged item been sent to the laundry/repair?*

Yes

No

Where did you purchase the item?*

What was the purchase price/value?*

In case of damage, do you have a money transfer receipt?*

Yes

No

Do you consent for SMGH to access relevant records for handling this incident?*

Yes

No

Today's Date*

What type of claim do you seek (repair, replacement, reimbursement)?*

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