Respironics CPAP Recall

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Who Is Completing This Questionnaire?* This field is required.
Patient
Spouse
Family Member
Caregiver
Friend
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Why Is Patient Unable To Complete?
Patient physically unable
Patient cognitively impaired
Patient clinically unable to be disturbed
Patient is a minor
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Who Is Completing The Questionnaire?
First Name
Last Name
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Patient Name* This field is required.Legal name as listed on your license
First Name
Last Name
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Date of Birth* This field is required.
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Month
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Day
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Year
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What is the best phone number to use to reach you?
Area Code
Phone Number
8
What email address can we use to reach you?
example@example.com
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Respironics Recall Notice* This field is required.
10
Is the brand of your PAP device Philips Respironics?IF your device (not your mask)is manufactured by any other company, please select "No" (Resmed, Devilbiss, 3B, Fisher and Paykel)
Yes
No
I don't know
11
Is your machine more than 5 years old?
YESNO
12
Have you been using your machine?
YESNO
13
Why have you not been using your machine?
Huge
Large
Normal
Small
Ok
Ok
14
Do you use Ozone Cleaner on your PAP Device? (If YES discontinue use immediately!) Ex: SoClean, Zoey, etc
YESNO
15
Per Respironics discontinue use of the Ozone cleaner immediately.
16
Is your AHI (Apnea Hypopnea Index) over 20 per hour?
Yes
No
I don't know
17
Do any of the following apply to you: Lung disease, Heart disease, High Blood Pressure, Cancer (Past/Present or Family History), Smoker, you hold a DOT license that requires treatment of Obstructive Sleep Apnea, kidney/renal transplant, you hold a safety sensitive job (operate heavy machinery, drive a car or truck, operate a train, operate a commercial boat, pilot an airplane, work in public safety or any other increased safety risk occupation)?
YESNO
18
Would daily life be challenging or impossible for you to discontinue use of your device until it is repaired or replaced? Select YES if your sleepiness before using PAP was severe or if you do not feel you can safely or adequately function in daily life without using your PAP.
YESNO
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We will contact you to arrange an evaluation regarding continued use of your machine. If your machine is manufactured by Respironics, please register for device repair/replacement with Respironics at philips.com/src-update or 877-907-7508 as soon as possible. I understand that due to the high volume of requests it may take some time for you to contact me.
20
Your device is not involved in the recall. Please continue use as usual. Thank you for taking the time to answer these questions.
21
Your device is likely involved in the Philips Respironics recall. Please register for device repair/replacement with Respironics at philips.com/src-update or 877-907-7508 as soon as possible. Your responses suggest you should CONTINUE USE OF YOUR DEVICE until it is repaired or replaced. Please read the following information and indicate your choice or request to be contacted for further discussion.
22
Your device is likely involved in the Philips Respironics recall. Please register for device repair/replacement with Respironics at philips.com/src-update or 877-907-7508 as soon as possible. Your responses suggest you should TEMPORARILY DISCONTINUE use of your device until it is repaired or replaced. Please read the following information and indicate your choice or request to be contacted for further discussion.
23
I understand the issues regarding the Philips Respironics PAP Device recall. I have been informed of the benefits and risks if I continue PAP therapy until Philips Respironics completes the device repair or replacement, or if I discontinue PAP therapy until the repair or replacement is completed. I release Delaware Sleep Disorder Centers LLC, its practitioners, affiliated companies, successors and assigns from any responsibility, future claim or liability that may occur because of my decision.* This field is required.
I choose to continue using PAP therapy until the device is repaired or replaced.
I choose to discontinue using PAP therapy until the devices is repaired or replaced.
I would like to speak to someone to help me decide. I understand that due to the high volume of requests it may take some time for you to contact me.
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Date Completed* This field is required.
Date
Year
Month
Day
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Time Completed* This field is required.
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Minute
PM
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PM
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Signature & SubmissionPlease sign your name.
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Tags
Todo
In Progress
Done
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