LifeVac Request Form

Please fill out the form below to request a LifeVac Home Kit. Upon submitting this request and confirming eligibility, we will ship out your device in the order your request was received. Please email LifeVac@curesma.org with any questions. We are unable to ship to P.O. boxes.

Package Includes:

LifeVac Home Kit
(1) LifeVac non-powered, non-invasive airway clearance device
(1) Adult mask
(1) Pediatric mask
(1) Practice mask

1. I acknowledge I have read through the eligibility criteria below and meet all of the requirements.

Eligibility Criteria:

Must have confirmed SMA diagnosis.
Must live within the United States.
A legal guardian can request device on behalf of their affected child if individual with SMA is under the age of 18.

*This question is required.

Are you affected by SMA or are you filling out this request on behalf of a person with SMA? *This question is required.