PAP Reorder Form


Please fill out this PAP reorder form to receive uninterrupted timely delivery of your pap supplies.
The more information you provide, the easier it is to process your reorder. The required fields are listed with a red asterisk (*).
If you have any questions please call our Customer Service Department at 1-888-246-7667.

Patient Information











Patient Status Questionnaire


Yes           No
Yes           No
Yes           No




Yes           No

Product Information


Yes           No
Same Style           New Style

Yes           No

Yes           No

Yes           No
Yes           No

Yes           No
          *Note this is separate from headgear




Submit Reorder Form

By filling out and submitting this application you are stating the following:
I have read and understand Binson's Terms & Conditions and the Privacy Policy.
I am giving Binson's Hospital Supplies permission to contact me.
I certify that the information provided on this application is accurate.

Binson's Hospital Supplies is dedicated to protecting your medical information.
We are required by law to maintain the privacy of protected health information.