Hour Meter Reading Form - HillRomRespiratory

Fill out the form below and a member of the Hill-Rom Respiratory Care team will be in contact with you.

Hour Meter Reading Form

All information collected must be for the patient

Patient Name*

Patient Date of Birth (MM/DD/YYYY)*

Main Phone Number*

Secondary Phone Number

Address

City

State

Zip Code

Email Address

Usage Information

Please type the reading from the total use display in the field below. The display reads to the tenth of the hour. Confirm your devices is turned on, at the Normal / Custom screen press the OFF button to obtain the hour meter reading.

Hours of Use (to one decimal point)*

Serial Number (seven digit number)

Date (MM/DD/YYYY)*

Clinical Follow-Up Please have a clinician contact me within the next 3 business days

*required

Respiratory Health

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Hill-Rom® Respiratory Care