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CPAP Prescription Form CPAP Prescription Form
Please ask your prescribing Doctor, Medical Professional or Clinician to fill in this form. Authorized Respironics Reseller
If you need help filling in this form please call 0844 504 9999. Note: We cannot be held responsible for any possible consequences arising from the inaccuracy of any of the information you submit.
Patient Details * Required Information
Patient's Name:  *
Address Line 1:  *
Address Line 2:  
City:  *
County:  *
Post Code:  * (Excluding ROI)
Country:  *
CPAP Machine and Mask Details *
CPAP Pressure:   Ramp Start Pressure:  
Ramp time:   Mask Type:  
  (5 minute increments)  
Humidifier:  (separate purchase) Mask Size:  
CPAP Unit:  
If REMstar Auto:   minimum cm pressure
  maximum cm pressure
Prescribing Professional's Details
Name:  *
Position:  *
Tel. Number:  *
Signature:  *
Hospital/Clinic:  *
Application Date:  *
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0844 504 9999

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Intus Healthcare Ltd
Therapeutic options for proactive people.