Name: 

Address: 

City: 

State/Prov.: 

Zip/Post Code: 

Telephone: 

Fax: 

E-mail: 

Name of current home oxygen provider: 

Best Time to Reach You 

I AM INTERESTED IN INFORMATION ABOUT THE:

Eclipse 1 

Eclipse 2 

Eclipse 3 

CHECK ALL OF THE BOXES THAT APPLY TO YOU

Concentrator 

Portable Concentrator 

Continuous Flow 

Pulse Dose 

Compressed Gas Tanks 

Liquid Oxygen 

C-Pap 

Bi-Pap 

Humidifier Bottle 

What is your diagnosis? Please describe below.

What is your Liter Flow Per Minute (LPM)?

How many hours per day do you use oxygen?

How many hours per day will you be mobile?

What is the name of your current oxygen provider?

Dates of travel: Cruise/Airline/Bus/Train/Hotel/Car

Destination

Name reservation is under

Cruise Line / Ship Name

Cabin #:/ Booking #: / Voyage #:

Airline(s) Name and Flight #(s)

Approximate Time of Departure

Approximate Time of Arrival

Roundtrip or One Way

Departure City/Country

Will you have any hotel stay either before or after your trip?
Yes No

If Yes please provide the hotel information below

Will you be taking any of your own equipment with you? Please 
describe below

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