*NEW* Sleep Apnea Refurbishment Program Application Form (CPAP)

Sleep Apnea Refurbishment Program Application (CPAP)

First Name

Last Name

Recipient First Name

Recipient Last Name

Recipient Address (include street name, number, province, and postal code)

Recipient Phone Number

Email Address

Type of CPAP Machine (if unsure, please check with sleep clinic or physician)

Auto CPAP

Fixed-Level CPAP

Please read and check EACH to indicate you have read and understand all of the following:

You acknowledge that your income does not exceed $35,000 (individual) or $60,000 (household)

We do not provide medical advice. You will need to seek medical advice around set up and use of the machine from your respiratory clinic or doctor.

If you need the machine delivered, you will pay $35.00 COD by Canada Post

If you provide us with the wrong machine type and need it replaced, you will go back on the waitlist

You will upload a copy of your sleep study

You will upload valid proof of income (Notice of Assessment) *We securely dispose after verifying

You will upload a copy of your prescription for a CPAP from a doctor

WAIVER AND RELEASE AGREEMENT

Use of CPAP or BiPAP Machine

ASSUMPTION OF RISKS

WAIVER AND RELEASE OF CLAIMS

INDEMNITY AGREEMENT

BY SIGNING THIS DOCUMENT, YOU WILL WAIVE LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE. PLEASE READ CAREFULLY.

I acknowledge that the CPAP or BiPAP machine I am receiving from LungNSPEI is a REFURBISHED/SECOND-HAND MACHINE, CLEANED BY STUDENTS, AND THAT ITS INTERNAL PARTS CANNOT BE FULLY SANITIZED.

I also acknowledge that tubing and masks will not be provided with the machine and it will be my responsibility to have the machine properly set-up for my measurements by a qualified nurse or respiratory therapist. I understand I am responsible for any fees that may incur for set-up, calibration and training purposes. These fees are not paid for by LungNSPEI or any party associated with this program.

I understand that there are KNOWN AND UNKNOWN RISKS OF USING A REFURBISHED/SECOND-HAND MACHINE THAT HAS NOT BEEN INTERNALLY SANITIZED including but not limited to INFECTIONS, BODILY HARM, PERSONAL INJURY, AND/OR DEATH.

I understand as well that infections, bodily harm, personal injury and/or death may be caused or contributed to by the NEGLIGENCE OR CARELESSNESS OF OTHERS INVOLVED IN THE REFURBISHING AND CLEANING OF THE CPAP OR BiPAP MACHINE THAT I RECIEVE. By signing this waiver, I agree to fully release LungNSPEI, Dalhousie University (including employees and students), and the Nova Scotia College of Respiratory Therapists from all claims, including in negligence.

IMPORTANT NOTE: Please be advised that LungNSPEI is not able to provide a back-up machine in the case of machine failure or power outage. Should the machine fail, LungNSPEI will make every effort to replace it as soon as possible.It is the responsibility of the borrower to have plans in place should they be completely dependent on the borrowed units. Please be advised that should the machine be too costly to fix or should there not be any replacement units in inventory, it is the responsibility of the borrower to source replacement. It is HIGHLY recommended that if you are using a Bi-PAP machine, that you talk to your health care and caregiving teams about putting an emergency plan in place in case of equipment failure or power outage. The plan should include the emergency after hours number for the vendor, an alternate source of power (generator, friend or family member in a nearby community, a public building/hotel/church with a generator that would give you permission to go there in the event of a power outage). You may wish to contact your local EMS service to file information about your situation so that there is a record in the event of an emergency. You may wish to plan to go to the local hospital/emergency department should you experience respiratory issues due to equipment failure/power outage. You should check with your local hospital to see if there is Bi-PAP equipment available in the event of an emergency.

If the machine is no longer required, I agree to return this machine to LungNSPEI. I agree I have no right to loan or re-sell this machine.

In consideration for LungNSPEI providing me with a CPAP or BiPAP machine, I acknowledge and agree, on behalf of myself, my heirs, assigns, personal representatives and next of kin, that:

1. I HAVE THOROUGHLY READ THIS WAIVER AND RELEASE IN ITS ENTIRETY AND FULLY UNDERSTAND ITS TERMS, INCLUDING THAT IT IS A RELEASE OF LIABILITY.

2. IN SIGNING THIS AGREEMENT, I AM VOLUNTARILY WAIVING SUBSTANTIAL LEGAL RIGHTS.

3. I AGREE THAT I HAVE THE MENTAL CAPACITY TO SIGN THIS RELEASE. IF I AM SIGNING THIS ON BEHALF OF ANOTHER PARTY, I AGREE I HAVE THE LEGAL AUTHORITY TO ACT ON THEIR BEHALF.

4. BY SIGNING THIS AGREEMENT, I WILLINGLY ASSUME AND ACCEPT, WITHOUT LIMITATION, ALL RISKS AND DANGERS ASSOCIATED WITH THE USE OF THE REFURBISHED/SECOND-HAND CPAP OR BIPAP MACHINE PROVIDED TO ME BY LUNGNSPEI INCULDING PERSONAL INJURY AND/OR DEATH.

5. I AM WAIVING ANY RIGHTS I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR CLAIM AGAINST LUNGNSPEI, DALHOUSIE UNIVERSITY (INCLUDING EMPLOYEES AND STUDENTS), AND THE NOVA SCOTIA COLLEGE OF RESPIRATORY THERAPISTS. THIS INCLUDES ALL BOARD OF DIRECTORS, EMPLOYEES, VOLUNTEERS AND VENDORS. I, FOR MYSELF AND FOR MY HEIRS, EXECUTORS AND ADMINISTRATORS, HEREBY ABSOLVE, REMISE AND RELEASE LUNGNSPEI, DALHOUSIE UNIVERSITY, AND THE NOVA SCOTIA COLLEGE OF RESPIRATORY THERAPISTS (INCLUDING ALL BOARD OF DIRECTORS, EMPLOYEES, VOLUNTEERS AND VENDORS) OF ANY RESPONSIBILITY OR LIABILITY OF WHATSOEVER NATURE OR KIND, INCLUDING IN NEGLIGENCE, SHOULD INJURY, DEATH, AND/OR DAMAGE OCCUR TO ME OR TO ANY OTHER THIRD PARTY DUE TO THE USE OR MISUSE OF THIS EQUIPMENT.

6. I UNDERSTAND THAT LUNGNSPEI IS RELYING ON MY FULL RELEASE AND WAIVER OF ALL CLAIMS PRIOR TO PROVIDING ME WITH A CPAP OR BiPAP MACHINE.

Signature

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Upload your sleep study results (document, photo, pdf, etc.)

Upload your file

Choose a file or drag and drop one here.

Upload your most recent CRA Notice of Assessment (document, photo, pdf, etc.)

Upload your file

Choose a file or drag and drop one here.

Upload your prescription from a doctor (document, photo, pdf, etc.)