RePAP

Sleep Therapy New Machine Request

Please fill out and submit the below form to begin the process of replacing your Sleep Therapy equipment.

Please note, along with this form, we will require the following documentation to qualify you for a new machine. Once we receive your request we will begin working with our clinician on obtaining this documentation.

Face to face office visit within the last 6 months discussing use and beefit of the equipment
New prescription that includes the appropriate pressure and related supplies
Recent compliance download

Name(Required)

First Middle Last

Date of Birth(Required)

Preferred Method of Contact(Required)

Phone

Email

Name of your Sleep/Pulmonary Doctor(Required)

Date of Last Appointment

Once able to dispense new machine, how would you prefer to receive it?(Required)

In-store appointment with respiratory staff

Virtual appointment with respiratory staff

Mailed to you - no appointment (free shipping!)

Pick-up in store (no appointment)

RePAP

Sleep Therapy New Machine Request

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