Patient Form

Patient Information

* - Indicates a required field

First Name *

Last Name *

Phone *

Email *

What type of CPAP/BiPAP do you own? *

Make: *

Model: *

What is your pressure setting? *

What mask are you using? (nasal, ffmask, pillow) *

What date did you receive the machine? *

What DME company provided the machine? *

What company are you using for supplies? *

When did you receive your last mask? *

What is the date of your last sleep diagnostic study? *

Where did you have your last diagnostic study? *

What is wrong with your current equipment? *

Why are you leaving your current provider? *

Have you seen a doctor in the last 6 months? *

Have you seen a doctor in the last 6 months? Yes No

Are you currently using supplemental oxygen? *

Are you currently using supplemental oxygen? Yes No

Do you have a humidifier? *

Do you have a humidifier? Yes No

Once all information is received, do you need to schedule an appointment? *

Once all information is received, do you need to schedule an appointment? Yes No

Do you use heated tubing? *

Do you use heated tubing? Yes No

Do you use non-heated tubing? *

Do you use non-heated tubing? Yes No

Supplies Needed: *

Once all information is received do you want the supplies shipped USPS? *

Once all information is received do you want the supplies shipped USPS? Yes No

Do you want to pick up the supplies at one of our locations?

Do you want to pick up the supplies at one of our locations? Yes