SLEEP THERAPY QUESTIONS? CALL: (877) 978-4038 REORDER SLEEP APNEA SUPPLIES PHCS Home Medical Equipment offers a wide variety of Sleep Apnea Treatment Supplies. Customer Information:First NameLast NamePhoneEmailPrimary PHCS OfficePHCS PHCS Panama CityPHCS PensacolaQRC PharmacyMask System: Mask Leakage, damaged or missing pieces and patient discomfort can negatively impact mask seal.Are you experiencing more "leaks" than when you first received your mask?(Required) Yes No NA Does your mask system have any damaged or missing parts or pieces?(Required) Yes No NA Are you experiencing any discomfort, skin redness, or irritation?(Required) Yes No NA If answers are NO, why does part need replacement?Quantity of supplies remaining? (please enter a number greater than or equal to 0)Cushions: Stiffening, changes in color and the appearance of pitting or tears may indicate potential bacteria build-up in cushions and can negatively impact mask seal.Has your headgear become stretched out?(Required) Yes No NA Do you find that you are now tightening your headgear more than when you first received your mask?(Required) yes No NA Are your Velcro tabs worn or damaged in any way?(Required) Yes No NA If answers are NO, why does part need replacement?Quantity of supplies remaining? (Please enter a number greater than or equal to 0.)Filters: Dirt build-up in filters can negatively impact quality of air delivered and therapy effectevness.Does your filter show signs of wear such as discoloration or dirt build up?(Required) Yes No NA If answers are NO, why does part need replacement?Quantity of supplies remaining? (Please enter a number greater than or equal to 0.)Tubing: The appearance of holes, cracks, and/or tears in tubing can negatively impact quality of air delivered and therapy effectiveness.Has your tubing developed tears, cracks, or the appearance of holes?(Required) Yes No NA If answers are NO, why does part need replacement?Quantity of supplies remaining? (Please enter a number greater than or equal to 0.)Humidifier Chambers: Dirt build-up and the appearance of cracks in humidifier chambers can all negatively impact quality of air delivered and therapy effectiveness.Do you see any cracks or pitted areas?(Required) Yes No NA If answers are NO, why does part need replacement?Quantity of supplies remaining? (Please enter a number greater than or equal to 0.) Δ
