UNITED STATES MEDICAL SUPPLY

Better Service, Better Care
Call us at 1.800.787.6331
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CPAP Mask Cushion Re-Order Form

You may receive 2 nasal cushions/pillows or 1 full face cushion per month in addition to the new mask every 3 months.

This form is NOT for the whole mask, only for the cushion/pillow.

  • Send me an order of cushions upon receipt of this form.
  • I use my mask at least 4 hours every 24 hour period.
  • I have used CPAP for the preceding 2 months.
Name: First | Last *
|    
Phone *
   
Cushion Mask Selection
Size
Mask Type: ST P S M L SW SH
Comfort Select
Comfort Gel
Optilife
Swift 2
Activa
Mirage Full Face
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United States Medical Supply • 8260 NW 27th Street, #401 • Miami, FL 33122

call us 1-800-7-USMED-1