Oxygen Inquiry Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Which Location will your preferred store be? Pick as many as apply

What are you looking for? (Stationary, Portable, Oxygen Assessment, Oxygen Supplies, etc)

Have you been assessed for Oxygen Therapy?

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

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

Please list your respiratory medications:

Do you have Insurance? We assist with insurance coverage the maximum possible.

Which Insurance company?

I Authorize Capital Home Medical Equipment (CHME) to contact me electronically and by phone.

Oxygen Therapy Inquiry