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Buying Group Credit Request

First Name

Last Name

Clinic Email Address

Clinic Name

Buying Group

Please select the Buying Group that you purchased your Rayne products from.

Account Number

Please enter your buying group account number.

Who is Your Rayne Representative?

Product Name and Size

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Item Number with Buying Group

Please enter the item number for the Rayne product as referenced with your selected Buying Group.

Best By Date on Product

Please note that products within 6 months of their best by date are not eligible for credit through the Buying Group.

Quantity to be Credited

Invoice Number*

*From original purchase

Date of Invoice

Reason for Credit

Please choose the most accurate selection.

Additional Notes:

If you choose 'Other' or need to provide additional information, please use this box.