Take Wellness Assessment

Reorder Sleep Apnea Supplies

Please fill out the form below to reorder your Sleep Apnea Supplies.

  • First Name:*
  • Last Name:*
  • Email:*
  • Phone Number:*
  • Account Number:

  • Thank you for your reorder. Please answer all these questions to determine what supplies you need.
  • Does my mask not perform effectively due to wear and tear or damage?

  • Does my mask leak more than when it was new?

  • Does my mask cause me discomfort, redness, or irritation?

  • Does my mask have an unpleasant odor and I'm unable to get it clean?

  • Have my cushions become cloudy and not as transparent?

  • Has the silicone on my cushion started to stiffen or is it pitted or torn?

  • Is my headgear stretched out or is it loose and no longer fitting correctly?

  • Am I tightening my headgear more than when it was new?

  • Are the velcro tabs worn, missing or damaged in any way?

  • Do my filter(s) show signs of wear such as a change in color or a dirty appearance?

  • Does my tubing have tears, cracks, or holes?

  • Is my current tubing dirty or has it changed color?

  • Has my humidifier chamber taken on an unpleasant faded or dirty appearance?

  • Does my current chamber have cracks or pitted areas?

  • If any items such as Shipping Address, Phone, Physician, or Insurance has changed, please tell us what has changed and add the new information below:

  • My name is My relationship to the patient is: and I give consent authorizing Med-Care Diabetic & Medical Supplies to send the next shipment.