Mask Fit Test Form

Step 1 of 3

Please select:*
- I am interested in scheduling a Mask Fit Testing Session
I understand that I must bring the mask that I want to be fit-tested to. Breath for Life does not supply fitted masks.*
- Yes
Please note: Wrap around the ear masks do not typically create a fit. Select a mask that has straps that are placed to the top of the head and the back of the neck. N95 masks that have breathing valves have been discouraged from use.
Please enter the date and time that you would like to be mask fit tested.*

Breath for Life will do its best to accommodate your request and will confirm whether your requested time is available. Appointments are on a first come first served basis and the office will provide you with alternate dates and times if your requested date and time is unavailable. Communication will be by email.
I agree that if I am late for my appointment, I will not be fit tested and will lose by payment.*
- I agree to the above.

Please Provide Your Name*
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
I agree that (if applicable) I will be clean shaven, will not eat, drink , smoke (vape), chew gum, use mouth wash, brush my teeth or engage in any other activity not listed that could affect my ability to smell or taste 20 minutes prior to fit testing.*
- Yes
Breath for Life uses Bitrex (a bitter agent) to fit test.
I understand that when confirmed by email, that if I do not show for my fit test, there will be no refund of my payment. Any time greater than 30 minutes late will constitute a no-show. Any cancellations or reschedules of the testing will result in a loss of fees. I also understand that if I cannot be fit tested to the mask that I supplied, I will be given up to one week to provide another mask for fit testing.*
- Yes

N95 Mask Fit ($50.00 plus tax)
Price:
Total
$ 0.00 CAD
CANCELLATION/RESCHEDULING POLICY
1. I understand that if I do not show for my fit test that there will be no refund of my payment. Any time greater than 30 minutes late will constitute a no-show. Any cancellations or reschedules of the testing will result in a loss of fees. I also understand that if I cannot be fit tested to the mask provided for any reason that there will be no refund of fees. This sale is considered final.
2. I agree that I will be clean shaven (if applicable), will not eat, drink , smoke (vape), chew gum or engage in any other activity not listed that could affect my ability to smell or taste.
Thank you for your patronage.
I have read and understand the policies.*
- Yes
By entering your name in the space provided, which represents your signature for yourself or someone else, you accept the terms and conditions of the policies which form a contract between you (the registrant) and Breath for Life. If you require to step outside of the contract, the policies will be applied with consistency and neutrality.

Please note that these policies are meant to be applied to everyone fairly and impartially if the terms of the contract are called into question or challenged.
I want to pay for my mask fit test.*
- Yes
I accept that the purchase of this course will appear as Breath for Life Inc on your credit card statement and that the amount that will appear on your credit card will not be contested as a fraudulent charge (this also applies if you are registering someone else into this course).*
- Yes
Credit Card
Card Details
Cardholder Name
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Mask Fit Test Form

Step 1 of 3

CANCELLATION/RESCHEDULING POLICY