Nose Brace(TM) Order Form

Nose Brace Order Form

Please email your answers to:

Please first copy and paste the following questions to your email, then answer all fourteen questions as applicable. If you have any questions, please email.

1. Date and Time:

2. Name of the person to use Nose Brace:

3. Male or Female?

4. DOB:

5. Shipping address:

6. Shipping telephone no:

7. Email address:

8. How did you hear about nose brace?:

9. Problem(s) with the nose (please describe in detail but no more than five lines):

10. Please list all surgeries on your nose:

a. For each surgery, provide the date, what was done, and location:

b. Do you have any significant amount of scarring, i.e. enough to block part of the airway and/or change the anatomy and the shape of inside either one of your nostrils as a result of surgery?

c. Is the sidewall of either nostril hardened (i.e. not flexible) as a result of surgery? If yes, please explain in a few sentences.

11. Please specify the most important goal you would like to achieve by using nose brace. Please make only one selection, by placing a mark to the left of it in the space provided:

( ) A. To open one or both of my nostrils and thus improve breathing (airflow) through my nose and therefore eliminate or substantially reduce problems like mouth breathing, snoring, sleep apnea, fatigue, etc., related to not being able to breathe well through my nose.

( ) B. Aesthetic improvement of my nose by changing the contours of one or both of my nostrils.

12. When you do the simple test of lifting the side walls of your nostrils (pull them away from the middle wall, one at a time), do you get noticeably better breathing throgh the left nostril, or through the right one, or through both? Which nostril allows better breathing in the test?

13. Specify the nostril for which you would like to order a nose brace (Left only, Right only, or Both):

14. Measurements -- preferably in millimeters, however, inches are fine, too. Please measure the distances AD and BC for each nostril, and also please measure AE. Please see the sketch below.

AE:

Left AD: Right AD:

Left BC: Right BC:

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