Standard Prescription Form

Just send us your prescription and we will set up the machine and then ship it to you.

We require the following information to set up your CPAP.

CPAP equipment purchased (please indicate prescription settings for selected products):

CPAP                          Pressure setting: ____cmH2O

Ramp time(0-45min): ____min     Starting ramp pressure: ____cmH2O             Pressure relief (max= 3):        OFF       1       2        3 (please circle)

APAP                     Min Pressure _______cmH2O   Max Pressure _______cmH2O           Ramp time(0-45min): ____min       Starting ramp pressure: ____cmH2O           Pressure relief (max= 3):         OFF           1          2          3  (please circle)

CPAP Mask                 NasalPillow__Nasal___Full Face       (please circle)