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30-Day Mask Guarantee Program - Australia

Replacement Mask Request Form


To be completed by CPAP Dealer

Does the patient claim to have been harmed while using this mask? * Yes No
Does the patient claim there has been a quality defect or fault with the mask? * Yes No


Initial Mask Used on Patient

(Please select one mask and size where appropriate) *

Nasal

Nasal Pillows

Full Face

Other Masks

Fit Details

(Please select all that apply) *

Patient preferred a different fit

Patient preferred a different size
Too large Too small
Too large Too small

Other Patient Preference

cmH2O

What mask did you provide as a replacement?

Status of original mask?

*

SureFit 30-day Mask Guarantee

Program Terms & Conditions
  • SureFit is limited to one replacement mask per customer
  • Fisher & Paykel Healthcare reserves the right to ask for the return of the used mask, in full and in its original packaging. If the original packaging cannot be supplied, a Fit Pack SureFit claim will be replaced as a single, medium size seal mask (S-M size seal in Evora Full and M-L size seal in Brevida)
  • Fisher & Paykel Healthcare reserves the right to cancel or modify this program at any time