Contact Information

name *

Phone *

Email *

Date of Birth *

Address *

Address Line 2

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ZIP Code *

I prefer to be contacted by:*
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I consent to receiving SMS (Text) messages from Carolina’s Hometown Respiratory for the following purposes: *

—Please choose an option—Replying to this message and/or future remindersReplying to this message, appointment reminders, and marketing messagesPlease do not send me an SMS (Text) messages in the future - please include your mobile number

Was there an Insurance Change?
If Yes, please provide new insurance details in the note section below.*
YesNo

Please note

All supplies ordered will be billed to your insurance and you may receive a bill if your deductible is not met or if you have coinsurance.

Different insurances have different rules. Medicare requires an annual prescription for continued coverage of PAP supplies. You may need to see your healthcare provider if you have not had an office visit in a year or more. We will determine what you are eligible for based on your insurance plan

Please select the supplies that you would like to have refilled

Please send me all supplies that I am eligible for and that my insurance will cover at this time

OR THESE SPECIFIC SUPPLIES:

Full Face Frame (Medicare: 1 every 3 months)

Nasal Frame (Medicare: 1 every 3 months)

Headgear (Medicare: 1 every 6 months)

Full Face Mask Cushion (Medicare: 1 every 3 months)

Nasal Cushion (Medicare: 2 each month)

Disposable Filters (Medicare: 2 each month)

Chinstrap (Medicare: 1 every 6 months)

Nasal Pillows (Medicare: 2 each month)

Reusable Filters (Medicare: 1 every 6 months)

Tubing (Medicare: 1 every 3 months)

Water Chamber (Medicare: 1 every 6 months)

I would like to pickup my suppliesI would like my order shipped

Other

I am interested in trying a new mask - I would like a virtual fitting.
I am interested in trying a new mask - I would like to come into the office for a fitting.

Note or Special Instructions (optional)