Oxygen Inquiry Form

Oxygen Therapy Inquiry
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which Location will your preferred store be? Pick as many as apply

Kanata (Hazeldean Mall)Barrhaven (Green Street Medical Building)Downtown (The Doctor's Building)Home Delivery
What are you looking for? (Stationary, Portable, Oxygen Assessment, Oxygen Supplies, etc)
Have you been assessed for Oxygen Therapy?

YesNo
Is there an Oxygen Therapy Rx from an Ontario- Registered Physician?

YesNo - I don't have one.No - I need to obtain one but no family physician
An Oxygen assessment is needed to determine the quantity (Flow) of oxygen that will be prescribed to you to maintain Saturations above a safe level as directed by your physician and assessed by the Respiratory Therapist.
Are you currently on any Respiratory Medications?

YesNo
Are you currently on CPAP/PAP Therapy or have been diagnosed with sleep apnea?

Yes - On CPAPYes - Oral ApplianceNo - No DiagnosisNo - Daignosed but not on therapy
Please list your respiratory medications:
Do you have Insurance? We assist with insurance coverage the maximum possible.

YesNo
Which Insurance company?

SunlifeSunlife 55555Canada LifeManulifeManulife Inidividual (17777FM)GreenshieldBlue CrossCoughlinSSQDesjardinsCooperatorsVictory Insurance (GSC)OTIP (Manulife or GSC)Johnson's Insurance
I Authorize Capital Home Medical Equipment (CHME) to contact me electronically and by phone.

YesNo
Should be Empty:

Oxygen Therapy Inquiry