Mask Return Form

30 Day Mask Guarantee Program Return Form

All sections must be completed.

Section 1

Address:(Required)
MM slash DD slash YYYY
NOTE: Mask guarantee is for 30 days only from date of fitting. Submissions after 30 days will be denied

Section 2

Was the patient harmed or injured while using this mask?(Required)
Is the mask broken or does it have a quality defect?(Required)

If you have answered 'YES' to either of these questions, do not use this form.

Instead, please call Quality Assurance at 1-312-997-9980

Section 3

Reasons for return (please check all that apply):(Required)

Section 4

Select original mask placed on patient (please check appropriate box):

Full Face Masks

Sunset Vesper Full Face Mask
Sol Full Face Mask
Sunset Adjustable Deluxe Full Face Mask
Sunset Deluxe Full Face Mask
Sunset Classic Full Face Mask
SleepNet Innova Full Face Mask
SleepNet Ascend Full Face
Circadiance Sleepweaver Anew

Nasal Masks

Sunset Vesper Nasal Mask
Sunset Adjustable Deluxe Nasal Mask
Sunset Clearsight Deluxe Nasal Mask
Sunset Deluxe Nasal Mask
Sunset Classic Nasal Mask
Sunset Deluxe Nasal Pillow
SleepNet iQ2 Nasal Mask
SleepNet Phantom2 Nasal Mask
SleepNet Innova Nasal Mask
SleepNet Ascend Nasal
Innomed Aloha Nasal Pillows
Circadiance Sleepweaver Advance
Circadiance Sleepweaver Elan

Section 5

What mask did you provide as a replacement?

Please check appropriate box below regarding the status of original mask.(Required)

Please return masks if still available to the following address:

ATTN: Returns
Sunset Healthcare Solutions
2725 Alft Ln
Elgin, IL 60124

Please allow 14 business day for processing (includes delivery time), but may take longer if item is unavailable.

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