Surgimed Corporation - Medical Supply Reordering

Name*

First Name

Last Name

Email Address*

Phone Number*

How can we help*

Please select items needed:

Full Face Mask

Please select reason for replacement

Broken/Damaged Leaks Stretched Worn Dirty

You are allowed 1 every 3 months of this item.

Replacement Interface/Full Face Mask

Please select reason for replacement

Broken/Damaged Leaks Stretched Worn Dirty

You are allowed 1 every 3 months of this item.

Nasal Mask

Please select reason for replacement

Broken/Damaged Leaks Stretched Worn Dirty

You are allowed 1 every 3 months of this item.

Replacement Nasal Cushion

Please select reason for replacement

Broken/Damaged Leaks Stretched Worn Dirty

You are allowed 2 per month of this item.

Interface/Nasal Mask

Please select reason for replacement

Broken/Damaged Leaks Stretched Worn Dirty

You are allowed 2 per month of this item.

Replacement Interface/Pillow Mask

Please select reason for replacement

Broken/Damaged Leaks Stretched Worn Dirty

You are allowed 2 per month of this item.

Replacement Nasal Pillows

Please select reason for replacement

Broken/Damaged Leaks Stretched Worn Dirty

You are allowed 2 per month of this item.

Nasal Mask with cushions or pillows

Please select reason for replacement

Broken/Damaged Leaks Stretched Worn Dirty

You are allowed 1 every 3 months of this item.

Headgear

Please select reason for replacement

Broken/Damaged Leaks Stretched Worn Dirty

You are allowed 1 every 6 months of this item.

Chin Strap

Please select reason for replacement

Broken/Damaged Leaks Stretched Worn Dirty

You are allowed 1 every 6 months of this item.

Tubing

Please select reason for replacement

Broken/Damaged Leaks Stretched Worn Dirty

You are allowed 1 every 3 months of this item.

Disposable Filters

Please select reason for replacement

Broken/Damaged Leaks Stretched Worn Dirty

You are allowed 2 per month of this item.

Non-disposable Filters

Please select reason for replacement

Broken/Damaged Leaks Stretched Worn Dirty

You are allowed 1 every 6 months of this item.

Tubing W/Integrated Heading Element

Please select reason for replacement

Broken/Damaged Leaks Stretched Worn Dirty

You are allowed 1 every 3 months of this item.

Replacement Humidifer Chamber

Please select reason for replacement

Broken/Damaged Leaks Stretched Worn Dirty

You are allowed 1 every 6 months of this item.

Please note, if you submit an order and our records indicate that you have already exceeded the allotted quantity for the current period, we will fill your order only in so far as to be compliant with standards.

By submitting this form, I confirm that I have exhausted my current supplies of these items.

Items

Entering items here does not constitute an actual order. We will review it and call/email you to finalize before filling.

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