Pause animation Home Oxygen Setup Form Customer Name Address Address Suburb State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Delivery Day Preference #1 Choose a dayMondayTuesdayWednesdayThursdayFriday Delivery Day Preference #2 Choose a dayMondayTuesdayWednesdayThursdayFriday Is there parking for a small van at the property? (similar to a ambulance size) Yes No Is there a lift or any stairs either leading into or inside the home? Yes No Are there any pets on the premises? Yes No Will a translator be needed to explain the equipment operating instructions? Yes No Are you using your Oxygen with Sleep Aponea treamtment (eg. CPAP)? Yes No Does anyone in the household smoke? Yes No Is there anyone in the home with an infectious disease such as COVID-19, chicken pox, measles, Meningococcal, etc? Yes No Any Additional Questions/Comments? Call Us Email Us
