Company Information:

Company Name *

Account Number
*If you don't know your account number,
please reach out to your contact at React Health,
info@reacthealth.com, or our team at (863) 226-6285. *

Contact Name *

Company Phone Number *

Email Address *

PO Number

Company Ship-to Address *

Address Line 2

City *

State *

Zip Code *

Mask Information (Original Mask Fitted to Patient):

Full Face Masks

Mask SKU - Siesta Full Face

Quantity

Mask SKU - Numa Full Face*
*Numa does not come in a fit-pack

Quantity

Nasal Masks

Mask SKU - Siesta Nasal

Quantity

Mask SKU - Viva Nasal

Quantity

Nasal Pillows Masks

Mask SKU - RIO Nasal Pillows

Quantity

Reason for Return:

Please select all that apply: *

Air Leaks/Poor Seal

Patient Dissatisfaction

Noisy

Other Other

Today's Date * +

Signature *

clear

The mask guarantee program applies to properly fitted masks and is valid for 30 days from the date of initial fitting. Submissions made after 30 days will be denied.
The company retains the right to cancel or modify this program at anytime.
The company may request the return of the mask.
Each customer is eligible for one replacement mask per patient.
Internet sellers and distributors are ineligible to participate in this program.

If a patient was injured while using this mask, or if the mask had a quality defect, please file a complaint on our service portal tab at www.reacthealth.com

For assistance with completing the form or if you require your account number, please contact our Customer Advocate team at (863) 226-6285.