Richland Sleep Center Order Form

To place an order, select the product you want to order. Fill in the information requested. We will call you to finalize the order. Please do not supply any financial information. We will bill your insurance company directly, or discuss payment with you when we call to finalize the order.

Last Name Required.

First Name Required.

Phone Correct format example: (888) 555-1212Correct format example: (888) 555-1212

eMail A value is required.

New Mask and Headgear: Yes No
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New Tubing: Yes No
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New Filters: Yes No
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Additional Information or Comments. Please indicate the type and size of items you want to order.
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By checking this box, I understand I am responsible for paying the shipping/handling along with the applicable Washington State sales tax on the CPAP and equipment and supplies.

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