Replacement CPAP equipment request form

Trust patients can use this form for ordering replacement CPAP equipment from the sleep team at The James Cook University Hospital.
  • cpap-air-filter-s8 Please select the filter you use, even if your current filter is not pictured. As we will be able to identify your specific filter from the records we have on file.
  • cpap-air-filter-s10 Please select the filter you use, even if your current filter is not pictured. As we will be able to identify your specific filter from the records we have on file.
  • nasal-pillows-mask Please select the mask type you use, even if your current mask is not pictured. As we will be able to identify your specific mask from the records we have on file.
  • nasal-mask Please select the mask type you use, even if your current mask is not pictured. As we will be able to identify your specific mask from the records we have on file.
  • full-face-mask Please select the mask type you use, even if your current mask is not pictured. As we will be able to identify your specific mask from the records we have on file.
  • cpap-water-chamber-s10 Please tick for all water chambers even if yours is not pictured here. We will be able to identify your specific water chamber from the records we have on file.
  • cpap-tubing Please tick for all tubing even if yours is not pictured here. We will be able to identify your specific tubing from the records we have on file.
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  • This field is for validation purposes and should be left unchanged.