30 Day Money Back Guarantee Form

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Money Back Guarantee Request Number

Full Name Of The Patient*

Please Select From The List Below Of Covered Masks*

Please Provide The Reason For The Patient's Request (e.g. uncomfortable fit)*

Which Mask Was Issued to the Patient as a Replacement?*

Has the Patient Reported Any Harm or Injury While Using This Mask?*

Has the Patient Reported a Quality Defect or Fault With the Item?*

If the product is faulty, please complete the appropriate form found here.

Contact Details for the Pharmacy Representative*

Full Name

Pharmacy Name*

Email Address*

Phone Number

Please Provide Any Further Information That May Assist Us