30-Day Mask Exchange Request

30-Day Mask Exchange Request

Contact Information

First name

Last name

Date of birth

Month

Day

Year

Phone number

Email

Eligibility

How many days have you used your current mask?

Less than 7 days

7–13 days

14–21 days

21+ days

Are you within your first 30 days of therapy?

Yes

No

Usage

Average nightly usage (hours)

0-3 hours

3-6 hours

Number of nights used in last 14 days

0–5

6–9

10–14

Primary Issue

Main issue with mask

Air leaks

Discomfort

Mask falls off

Breathing issues

Claustrophobia

Dryness

Noise

Other

If Other please explain

Troubleshooting

Select what you have already tried

Adjusted headgear

Repositioned mask lying down

Wore mask before sleep

Tried different sleep positions

Cleaned mask

Reviewed instructions or spoke with support

Section 5: Fit and Sizing

Mask size

Small

Medium

Large

Not sure

Where are leaks occurring?

Nose

Mouth

Eyes

Sides

No leaks

Do you breathe through your mouth?

Yes

No

Not sure

Behavior

How long do you wear mask before removing?

1-2 hours

2-4 hours

4 + hours

What causes you to remove the mask?

Acknowledgements

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

Section 8: Request

Mask type you want to try

Additional comments

30-Day Mask Exchange Request