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Order Supplies Option
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Email
(Required)
Are you a new or existing customer?
I am an EXISTING customer
I am a NEW customer
NEW PATIENTS / TRANSFER OF CARE
We’re grateful you’ve chosen to start your sleep care with the Sleep Metrics family! Providing us with the information below will help ensure a smooth transfer to our care.
First and last name
(Required)
Best phone number to reach you
(Required)
Who is your sleep doctor?
(Required)
Who is your current sleep product provider?
(Required)
Name
(Required)
First
Last
Phone number
(Required)
Address
(Required)
Patient ID (if you know it)
What supplies do you need?
(Required)
ALL SUPPLIES (full quarterly resupply)
Full Face Cushion (1 per month)
Nasal Cushion (2 per month)
Nasal Pillow Cushion (2 per month)
PAP Mask (Frame and headgear) (1 per 3 months)
PAP Tubing (1 per 3 months)
Disposable Filter (pack of 6) (2 per month)
Non-disposable Filters (1 per 6 months)
Humidifier Chamber (1 per 6 months)
How would you like us to address your needs?
(Required)
Please ship the product I’m due and bill my insurance
Please contact me before you send me anything
Questions and comments
Are you on Medicare?
(Required)
Yes
No
If you are a Medicare patient you will be asked to respond to a number of questions related to the sleep supplies you are currently using.
FOR MEDICARE PATIENTS
Medicare requires that you answer the following questions in order for us to fulfill a resupply request.
Have you started to experience more leaks than when you first received your mask?
(Required)
Yes
No
I don’t know
Does your mask system have any damage or missing parts?
(Required)
Yes
No
I don’t know
Have you started to experience any discomfort, redness or skin irritation?
(Required)
Yes
No
Is your cushion starting to change color (ex: opaque/cloudy/not as transparent)?
(Required)
Yes
No
Has the silicone on your cushion started to stiffen?
(Required)
Yes
No
Does your cushion appear to be pitted or torn?
(Required)
Yes
No
Are you experiencing any air leaks? Does it feel like air is escaping more than usual?
(Required)
Yes
No
Has your headgear become stretched out?
(Required)
Yes
No
Are you now over-tightening your headgear more to secure the mask?
(Required)
Yes
No
Is your velcro tab worn or damaged in any way?
(Required)
Yes
No
Does your filter show signs of wear?
(Required)
Yes
No
Does your filter have any discoloration or dirt buildup?
(Required)
Yes
No
Has your tubing developed tears, cracks or the appearance of holes?
(Required)
Yes
No
Has the tubing changed color or do you suspect any bacteria or mold buildup?
(Required)
Yes
No
Is any air leaking out of the tubing?
(Required)
Yes
No
Has your water chamber become discolored or cloudy in appearance?
(Required)
Yes
No
Do you see any cracks or pitted areas in your water chamber?
(Required)
Yes
No
First and last name
(Required)
Best phone number to reach you
(Required)
Who is your sleep doctor?
(Required)
Who is your current sleep product provider?
(Required)
Untreated Sleep Apnea can cause severe health risks,
and drastically impact your lifestyle
The road to a better lifestyle starts here
Take the Quiz
