I agree to the following by submitting the form below:

  • Send me a new mask and tubing upon receipt of this form, or after 90 days since my last mask, whichever is later.
  • I use my mask at least 4 hours every 24 hour period.
  • I have used CPAP device for the preceding 2 months.
  • I will continue my CPAP therapy.
  • I acknowledge receiving my last shipment.

First Name:

Last Name:

Email: (Example: name@emailbox.com)

Phone Number: (XXX-XXX-0000)

Account Number: (optional)

Thank you for your reorder. Please answer all these questions to determine what supplies you need.

Mask
Is it damaged or missing parts?
Is it causing discomfort, redness, or skin irritation?
Is it leaking more than it was when it was new?
Does it smell bad or are you unable to get it clean?
Cushion
Have your CUSHIONS started to change color (opaque/cloudy/not as transparent)?
Has the silicone on your cushion started to stiffen or does it appear to be pitted or torn?
Headgear
Has you headgear gotten stretched out or is it no longer fitting correctly?
Are you tightening your headgear more than normal?
Are your velcro tabs worn or damaged in any way?
Filters
Does your filter shows signs of wear such as discoloration or and dirt build up?
Tubing
Does your current tubing have tears, cracks, or holes?
Is your current tubing dirty or discolored?
Water Chamber
Is your current humidifier chamber discolored or cloudy?
Does your current chamber have cracked or pitted areas?
 

Notes / Comments: (optional)




I acknowledge receiving my last shipment. I am nearly exhausted of my supplies, and require that you send my next shipment of supplies when due. I acknowledge receiving the supplier standards, warranty info and training materials. I authorize the company to renew my prescription, to verify my insurance benefits, to contact me, to request and accept the release of my relevant medical records, and to submit claims and claim assignment of payments of medical benefits for items/services provided to me.