SomnoGuard AP Order Form

Please fill in the fields below to purchase your SomnoGuard AP and pay using a credit card. When you click on the 'Pay with Credit Card' button you will be directed to our secure PCI compliant payment processing page to enter your credit card information.
Item: Part #03050000
Description: SomnoGuard AP
*First Name:
*Last Name:
*Zip:
Physician's Name:
Rx Ref#:
A prescription is required in order for us to ship this product. If you already have a prescription, please enter the name of the prescribing physician and the Rx Ref#. If you do not yet have a prescription, leave this blank and we will contact you to assist in obtaining one.
Price: $489.00 + $7.95 Shipping/Handling
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