Signature/Maverick Order Form

READY TO PLACE YOUR ORDER?

Your order is auto-generated from this form. Please fill it out carefully. For tracking purposes, orders are not accepted over the phone and must be placed using this form. Have questions or need assistance? You can call us at 502-225-4772
It looks like you are trying to order after 2pm EST. -This order will ship on the next normal business day.

Equipment is not shipped out on weekends or holidays.
Important things to know-
We must receive your complete and accurate order in our system by 2pm EST. on normal business days to send the equipment out for next day delivery. If you are using the backup equipment- select replacement backup BiPAP or CPAP as appropriate below and follow the instructions.

Equipment is not shipped out on weekends or holidays. Weather related issues can delay shipment.
Current Time Is

:AM/PM Option
Lets get started-

First, please let us know who you are-
Your Name And Title*

NameTitle
Your Email Address*
Order and shipping confirmation will go to this email
Just in case we have questions, give us a number to call.

A cell number makes it so much easier!
An Easy Number To Reach You At (Cell Phone if Possible)*

Area CodePhone Number
Next we need your facility and resident information-

If you are requesting a replacement backup unit, you can write "BACKUP" in all three blanks for the resident name and room number
Resident Information-*

First NameLast NameRoom Number
Facility*
Don't Need A Machine? Is This For Supplies Only? Select Yes Below, Then Choose Your Supplies!

If you need to special order supplies that aren't listed, scroll down to the option "SPECIAL ORDER" under the supply type. Please be sure to put as much information in the "optional info" section as possible, we will call you if we need more information. Please note that in general, special order items take longer to process and ship and are not returnable.
Is This An Order For SUPPLIES ONLY?*

YESNO
Supplies Only Order- You Can Choose More Then One!*
You DO need a machine? Select the equipment type below- If you want to return something, choose CALL TAG! If you need a new backup, choose the correct REPLACEMENT BACKUP option

If your not positive what you need, click on a piece of equipment to see a sample of what the RX will look like.
Equipment Type:*

CPAPAuto CPAPBiPAPAuto BiPAP (Fixed Pressure Support)Auto BiPAP (Pressure Support Range)BiPAP STAVAPSTRILOGY Vent With HumidifierTRILOGY Vent Without Humidifier50PSI Compressor w/setup kitAirvo High Flow HumidificationReplacement Backup BiPAPReplacement Backup CPAPCall Tag for return of equipment
Review the RX and input in the settings-

Just type the prescription information on the dotted line(s).
Ordering A Trilogy Ventilator or AVAPS?

Please fill out the requested information listed below (You must have all the information necessary).
CPAP Setting*
Auto CPAP has two pressure levels- a max and min. The rx might read Auto CPAP 4-20cm H20*
BiPAP has two pressure levels- an IPAP and EPAP. The rx might read BiPAP- IPAP 16 and EPAP 8cm H20*
Auto BiPAP has a MAX IPAP and a MIN EPAP as well as PRESSURE SUPPORT SETTING. The rx might read Auto BiPAP Max IPAP 18 Min EPAP 4 and pressure support of 6. *
Auto BiPAP has a MAX IPAP and a MIN EPAP as well as PRESSURE SUPPORT SETTING. The rx might read Auto BiPAP Max IPAP 18 Min EPAP 4 and pressure support PS MIN 6 and PS min 4. *
BiPAP ST has two pressure levels- an IPAP and EPAP as well as a Backup Rate. The rx might read BiPAP- IPAP 16 and EPAP 8cm H20 and BACKUP RATE of 16 *
AVAPS *
Trilogy Ventilator With Humidifier*
Trilogy Ventilator Without Humidifier*
Airvo High Flow Humidification System- Airvo is programmed at the facility, Once it arrives, setup instructions are included in the setup kit as well as assistance with programming by phone-please select an option below.*

Airvo Setup Kit With Trach MaskAirvo Setup Kit With Nasal Cannula
You used/are using the Backup BiPAP for your facility. In order to get a replacement, you must fill out the information below. For proper billing we need to know what mode you placed the BiPAP in.

Please check the backup machine for the "M-Tag" that will look similar to the picture below.

Who did you use the equipment on? Please fill out the information below!

  BiPAP   Auto BiPAP   BiPAP ST*
Name: First Name*   Last Name*
Room #Room Number*
Start Date:   Date*
M-TAG   M-Tag#*
You used/are using the Backup CPAP for your facility. In order to get a replacement, you must fill out the information below.

Please check the backup machine for the "M-Tag" that will look similar to the picture below.

Who did you use the equipment on? Please fill out the information below!

Name:   First Name*   Last Name*
Room#   Room #*
Start Date   Date*
M-TAG:   M-Tag#*
You are requesting a call tag for return of equipment.

Please look carefully for the "M-Tag" on the equipment that will look similar to the picture below. We must have this information to properly process your order.

We need to know the following to properly process your request!
Residents Name First Name* Last Name*
M-TAG M-Tag* of the unit you are requesting a call tag for. Please package the unit carefully and remove ALL disposable supplies including the water chamber, tubing and mask. Facility is responsible for the full cost of the unit if damaged due to improper return shipment.
Time to choose a mask-

Pick a mask from the list below
Use the dropdown list to select the correct mask for your resident*
TRILOGY With Humidifier-Use the dropdown list to select the correct mask for your resident*
TRILOGY Without Humidifier-Use the dropdown list to select the correct mask for your resident*
Almost Done....OPTIONAL INFO

Use the box below to add any additional information about your order.
Anything you need to let us know?
Last Step- Check the box below to indicate you understand our terms and conditions, then click submit. An email with confirmation will head your way shortly.
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Should be Empty:

READY TO PLACE YOUR ORDER?

It looks like you are trying to order after 2pm EST. -This order will ship on the next normal business day.

Important things to know-

We must receive your complete and accurate order in our system by 2pm EST. on normal business days to send the equipment out for next day delivery. If you are using the backup equipment- select replacement backup BiPAP or CPAP as appropriate below and follow the instructions.

Lets get started-

Just in case we have questions, give us a number to call.

Next we need your facility and resident information-

Don't Need A Machine? Is This For Supplies Only? Select Yes Below, Then Choose Your Supplies!

You DO need a machine? Select the equipment type below- If you want to return something, choose CALL TAG! If you need a new backup, choose the correct REPLACEMENT BACKUP option

Review the RX and input in the settings-

Ordering A Trilogy Ventilator or AVAPS?

Time to choose a mask-

Almost Done....OPTIONAL INFO

Last Step- Check the box below to indicate you understand our terms and conditions, then click submit. An email with confirmation will head your way shortly.

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