Name:

Please complete the PAP equipment & supply checklist to proceed with your order. Tick appropriate boxes to indicate your answers.

  1. What PAP equipment do you need?
    New Machine




    Machine Replacement
  2. Do you need PAP Supplies? (Please select all that apply)
    No
    Yes



    Filters
    Humidified Water Chamber
    Tubing/Hose
  3. Do you have your own or preferred Durable Medical Equipment vendor? (If yes, please specify)
    No
    Yes
  4. Do you have a prescription?
    No
    Yes
  5. Do you have the following medical records? (Please select all that apply)
    No
    Yes



Submit

Thank you for completing the checklist
Please have your medical documents available and you will be contacted by Nationwide Medical Inc.

Should you have additional questions, you may call them directly at 877-307-2727 / 818-338-3500.