Support

New Patient 30 Day Mask Exchange Request

New patients only: use this form to request a mask exchange within 30 days of your setup. Exchanges outside 30 days are not eligible.

Patient Information

First name *

Last name *

Date of birth *

Phone number *

Email address *

How many days have you used your current mask? *

Are you within your first 30 days of therapy? *

Average nightly usage *

Number of nights used in the last 14 days *

Main issue with your mask *

If Other, please explain

Select what you have already tried

Mask size *

Where are leaks occurring? *

Do you breathe through your mouth? *

How long do you wear the mask before removing it? *

What causes you to remove the mask?

I have used the mask at least 14 days *

I understand most issues improve in 2–3 weeks *

I understand only one exchange is allowed *

Mask type you want to try *

Additional comments

Your information is sent securely to Medigy and used only to process this request. Questions? Contact us.