I agree to the following by submitting the form below:

You must agree to the Terms and Conditions.

• 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:

Please enter your first name

Last Name:

Please enter your last name

Date of birth:

Please enter a valid date of birth Invalid Date format. Valid Date Format dd/MM/yyyy

Email: (Example: name@emailbox.com)

Please enter your email address Please enter your valid email address

Phone Number: (XXX-XXX-0000)

Please enter your phone no. Please enter a valid phone no.

(Please use the number we have on file for you)

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

Please answer all questions

To update your account information, please click here: https://www.usmed.com/current-patients/change/

Sorry, we couldn't process your order at this time, please call us at 1-866-723-6958 to place your order.