Date of birth
If your occupation involves driving, please select it here
Have you been diagnosed with OSA?
If yes, which year were you diagnosed
Which Sleep Centre were you diagnosed at?
How many nights per week do you currently use your CPAP equipment?
If applicable, your current OR preferred mask
Quattro Air for Her
Quattro FX for Her
Ultra Mirage Full Face Mask
Mirage Full Face Mask Series 2
Swift FX Nano
Swift FX Nano for Her
Mirage FX for Her
Mirage Activa LT
Ultra Mirage II Nasal
Swift FX for Her
Swift FX Bella (pink)
Swift FX Bella (gray)
Other nasal mask
Other full face mask
Other nasal pillows mask
If applicable, your current OR preferred device
S8 Autoset/Autoset II
S8 Escape/Escape II
Is your equipment usually supplied by your NHS Sleep Centre?
NHS Sleep Centre
Do you purchase your own equipment?
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