MaskFit AR | Questionnaire

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Questionnaire (AmeriMed Pharmacy & Equipment - 3782 Old US Hwy 41 N, Valdosta)

First name

Last Name

Gender

Year of BirthDate of Birth *

Email * (Email or Phone number is mandatory)
[[formErrors.email]]

Mobile Number (Email or Phone number is mandatory)
[[formErrors.phoneNumber]]

Region

State/Province

Do you have a preferred mask style?

[[ mask_style_preference_note ]]

[[formErrors.pickedMaskStyle]]

No Preference/New Setup

Standard Full Face

Under the Nose Full Face

Standard Nasal

Under the Nose Nasal

Nasal Pillow

Do you have a deviated septum? * [[formErrors.pickedSeptum]]

Yes

Do you have chronic nasal congestion? * [[formErrors.pickedCongestion]]

Yes

Do you experience seasonal allergies? * [[formErrors.pickedAllergies]]

Yes

What is your preferred sleep position? * [[formErrors.pickedSleep]]

Restless

Side

Stomach

Back

Do you have facial hair * [[formErrors.pickedHair]]

None

Mustache

Full Beard

Stubble/Goatee

Do you have any skin sensitivities on your face? * [[formErrors.pickedSkin]]

Yes

Are you claustrophobic? * [[formErrors.pickedClaustrophobic]]

Yes

Do you (or your bed partner) have a medical condition or any implanted device that prevents the use of magnets? * [[formErrors.pickedMagnetic]]

Yes