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									                       OXYGEN CONCENTRATOR CHECKLIST

1.    Instructed how to place concentrator in a central area so that customer can reach all
      areas of the house.
2.    Customer instructed to keep concentrator away from heat register, curtains, and any
      close-in area.
3.    Customer instructed on location and proper care of filters.
4.    Customer instructed on location, use and filling of humidifier, if applicable.
      Customer should demonstrate knowledge.
5.    Customer instructed on startup of concentrator and given an instruction manual.
6.    Customer instructed to adjust flowrate. NOTE: Patient should test by placing nasal
      prongs in glass of water.
7.    Customer instructed on attachment of oxygen connecting tubing and nasal cannula.
8.    Customer instructed on concentrator alarm system and troubleshooting techniques.
9.    Customer instructed to clean unit with damp cloth only.
10.   Customer instructed on cleaning of disposable equipment,
11.   Appointment will be made to see customer in his/her home in approximately 4-6
12.   Customer instructed on the use of portable oxygen unit.
13.   Customer instructed on safety precautions associated with the use of oxygen.
14.   Concentrator should be plugged into a properly grounded outlet. Extension cords
      should not be used.
15.   Customer instructed on 24 hr. service availability. Brochure given to customer.
16.   Customer informed of billing procedure.

I certify that I have read and agree to all the items in this checklist. The sole liability of
________________________________ (Company Name) for rented equipment that becomes
unsafe or in need of repair is to replace the equipment with comparable equipment.

The sole liability of ________________________________ (Company Name) for purchased
equipment is to honor the terms of the manufacturer’s warranty.

Customer/Authorized Representative/Relationship

Company Representative                                                  Date

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