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Physician Office Order Form

Order nebulizer products for in-office use. Complete the form below to submit your order. Get Started

Orders placed prior to 2:00 PM will be received on the following business day
Search and Select Your Facility:
Facility Name*
Please confirm the facility name above is correct*
- Please check this box to confirm the facility name selected above is correct
Person Placing Order:
First Name*
Last Name*
Email*
Telephone*
Nebulizer Compressor Kit (compressor, nebulizer, mask):
Compressor - $55.00
Disposable Nebulizers and Accessory Kits:
Please note: for disposable units, there is a quantity of 50 in each box.
PARI LC®D Disposable Nebulizer w/Bubbles The Fish Mask - 022H73P50 - $180.00
PARI Bubbles The Fish Mask - 044F7254 C/50 - $80.00
Respironics Sami the Seal Pediatric Mask - HS880 C/50 - $80.00
Respironics Sidestream® Disposable Nebulizer - HS800 - $60.00
Respironics Innospire Filters - 1114112P C/50 - $50.00
Spacers:
Please note: there is a minimum quantity of 10
Respironics Optichamber Diamond - 1077478 - $115.40
Respironics Optichamber w/ Small Mask - 1079823 - $199.50
Respironics Optichamber w/ Med Mask - 1079826 - $199.50
Respironics Optichamber w/ Large Mask - 1079827 - $199.50
Ship To:
Facility Name*
Attention To*
Street Address*
Address Line 2
City*
State*
Zip*
Bill To:
Please Bill To:*
- The address I provided above
- An alternate address
Facility Name*
Billing Contact Name*
Street Address*
Address Line 2
City*
State*
Zip*
Billing Contact Email*
Billing Contact Phone*
Notes