Pediatric Replacement Mask for LifeVac

Have you had to use your LifeVac? We'd love to hear about it!

Fill out the form below and receive a FREE LifeVac replacement!

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If you have used your LifeVac to save a life,please fill out the form below to receive a free replacement of your LifeVac unit.

Date of Incident

Location of the Incident

Patient Name

Age of Patient

Patient Male or Female

Male Female

Any known medical conditions?

Yes No Unknown

Object that created the blockage

Partial or Total Blockage? (If known)

-- Please Select Partial Total Unknown

Position of the patient when LifeVac was used

Was the patient conscious of the time (LifeVac)?

Yes No

Was the Heimlich maneuver/back blows performed?

Yes No

Number of times LifeVac was used?

Outcome

Do you feel LifeVac saved the life of the person choking?

Your contact information to receive FREE LifeVac

Your Full Name

Phone

Email Address

Preferred Way of Contact

Phone Email

Address

Address Line 2

City

State

ZIP Code

How did you hear about LifeVac?

Submit

LifeVak replacement pediatric mask for children. It is recommended to replace your mask every 2-3 years for optimal results.

*Important Note* LifeVac masks are for use exclusively with the LifeVac Choking Rescue Device. The masks are not compatible with other devices such as BVMs and do not include a filter for rescue breathing.