Oxford Partial Knee Warranty Claim Form
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1Oxford
Partial Knee Warranty Claim Form
®
Please note: Claim Form must be returned within 5 days of revision surgery.
Hospital Name
Customer Account Number
Address
Street Address
Address Line 2
City
State
Postal/Zip Code
Surgeon Name
First
Last
Suffix
NPI #
Patient Name
Title
First
Last
Suffix
Street Address
Address Line 2
City
State
Postal/Zip Code
Date of Birth
Gender
Product will be returned?
Male
Female
Yes
No
MM
DD
YYYY
Original Surgery Date
Revision Surgery Date
If yes Zimmer Biomet will
(must be after September 10, 2012 for patients who received
contact you w/CMP & RGA #
an Oxford Knee with Signature technology or April 29, 2013
for all other Oxford Knee patients)
MM
DD
YYYY
MM
DD
YYYY
Reason for Revision:
*Attach invoice of original surgery or sticker sheet of op notes from original surgery.
Ref #
Lot #
Original Oxford
Revision Implant Component(s)
Oxford Bearing
Knee Implant
Left Knee
Total Knee
Right Knee
Revision Knee
Ref #
Lot #
Revision Implant Sticker(s)
Ref #
Lot #
Zimmer Biomet Representative Name (Printed)
Ref #
Lot #
Zimmer Biomet Representative Signature
Date:
MM
DD
YYYY
Distributor
Part 1 — Patient Chart Hospital
Click Here to Submit to Zimmer Biomet Customer Service
Part 2 — Zimmer Biomet Customer Operations
Part 3 — Surgeon
CONFIDENTIAL PERSONAL HEALTH INFORMATION. If you are not the intended recipient, please contact Zimmer Biomet
customer service at or destroy.
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