Email: fitmaskfittesting@gmail.com Telephone: 519-200-2567

Book an Appointment

Please complete the form to book an appointment:

Respirator User Information Form Used in conjunction with CSA Standard 294.4, Clause 11
First and Last Name:
Telephone Number:
Email Address:
Employer/School:
Job Title/Program:
Please indicate if you have any of the following: Respiratory conditions Cardiac conditions Panic attacks/claustrophobia Reduced sensitivity to smell/taste Skin conditions Allergies Other If you have selected other, please specify:
Have you had any previous difficulty with using an N95 respirator? Yes No N/A Do you have any concerns regarding the use of an N95 respirator? Yes No N/A
If you have checked off any health or medical conditions above, you may be required to obtain medical clearance by your family physician to be mask fit tested.
Comments/Concerns: