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PLEASE FAX SLEEP STUDY AND VISIT NOTES (pre and post SS) TO OUR OFFICE WHEN THIS FORM IS COMPLETE

FAX: 888-806-1535

First Referring Physician Name

First Name*

Last Name*

Phone*
First Referring Physician Age Acknowledgment*
First Referring Physician Date of Birth*
I certify that I am 18 years of age or older
First Referring Physician Fax number

Referring physician's Office name and location (City, St)

PATIENT'S DEMOGRAPHICS


Full Name

Date of Birth

Phone Number

Email
Does this patient have insurance?*
Yes
No
Unsure

Who is their insurance provider?
DX CODE*
G47.33 OBSTRUCTIVE SLEEP APNEA
Prescribed Services
E0486 CUSTOM ORAL APPLIANCE TO TREAT OSA
HOME SLEEP STUDY
History and Symptoms
Witnessed Apneas
Impaired Cognition
Excessive daytime sleepiness
Loud snoring often interrupted by silence & gasps
Obesity
Mood disorder
Hypertension
Insomnia
Stroke
Heart disease

Click to customize text box label
First Referring Physician Signature*
Second Referring Physician Name

First Name*

Last Name*
Second Referring Physician Date of Birth*
Second Referring Physician Fax number

Referring physician's Office name and location (City, St)

PATIENT'S DEMOGRAPHICS


Full Name

Date of Birth

Phone Number

Email
Does this patient have insurance?*
Yes
No
Unsure

Who is their insurance provider?
DX CODE*
G47.33 OBSTRUCTIVE SLEEP APNEA
Prescribed Services
E0486 CUSTOM ORAL APPLIANCE TO TREAT OSA
HOME SLEEP STUDY
History and Symptoms
Witnessed Apneas
Impaired Cognition
Excessive daytime sleepiness
Loud snoring often interrupted by silence & gasps
Obesity
Mood disorder
Hypertension
Insomnia
Stroke
Heart disease

Click to customize text box label
Third Referring Physician Name

First Name*

Last Name*
Third Referring Physician Date of Birth*
Third Referring Physician Fax number

Referring physician's Office name and location (City, St)

PATIENT'S DEMOGRAPHICS


Full Name

Date of Birth

Phone Number

Email
Does this patient have insurance?*
Yes
No
Unsure

Who is their insurance provider?
DX CODE*
G47.33 OBSTRUCTIVE SLEEP APNEA
Prescribed Services
E0486 CUSTOM ORAL APPLIANCE TO TREAT OSA
HOME SLEEP STUDY
History and Symptoms
Witnessed Apneas
Impaired Cognition
Excessive daytime sleepiness
Loud snoring often interrupted by silence & gasps
Obesity
Mood disorder
Hypertension
Insomnia
Stroke
Heart disease

Click to customize text box label
Fourth Referring Physician Name

First Name*

Last Name*
Fourth Referring Physician Date of Birth*
Fourth Referring Physician Fax number

Referring physician's Office name and location (City, St)

PATIENT'S DEMOGRAPHICS


Full Name

Date of Birth

Phone Number

Email
Does this patient have insurance?*
Yes
No
Unsure

Who is their insurance provider?
DX CODE*
G47.33 OBSTRUCTIVE SLEEP APNEA
Prescribed Services
E0486 CUSTOM ORAL APPLIANCE TO TREAT OSA
HOME SLEEP STUDY
History and Symptoms
Witnessed Apneas
Impaired Cognition
Excessive daytime sleepiness
Loud snoring often interrupted by silence & gasps
Obesity
Mood disorder
Hypertension
Insomnia
Stroke
Heart disease

Click to customize text box label
Fifth Referring Physician Name

First Name*

Last Name*
Fifth Referring Physician Date of Birth*
Fifth Referring Physician Fax number

Referring physician's Office name and location (City, St)

PATIENT'S DEMOGRAPHICS


Full Name

Date of Birth

Phone Number

Email
Does this patient have insurance?*
Yes
No
Unsure

Who is their insurance provider?
DX CODE*
G47.33 OBSTRUCTIVE SLEEP APNEA
Prescribed Services
E0486 CUSTOM ORAL APPLIANCE TO TREAT OSA
HOME SLEEP STUDY
History and Symptoms
Witnessed Apneas
Impaired Cognition
Excessive daytime sleepiness
Loud snoring often interrupted by silence & gasps
Obesity
Mood disorder
Hypertension
Insomnia
Stroke
Heart disease

Click to customize text box label
Sixth Referring Physician Name

First Name*

Last Name*
Sixth Referring Physician Date of Birth*
Sixth Referring Physician Fax number

Referring physician's Office name and location (City, St)

PATIENT'S DEMOGRAPHICS


Full Name

Date of Birth

Phone Number

Email
Does this patient have insurance?*
Yes
No
Unsure

Who is their insurance provider?
DX CODE*
G47.33 OBSTRUCTIVE SLEEP APNEA
Prescribed Services
E0486 CUSTOM ORAL APPLIANCE TO TREAT OSA
HOME SLEEP STUDY
History and Symptoms
Witnessed Apneas
Impaired Cognition
Excessive daytime sleepiness
Loud snoring often interrupted by silence & gasps
Obesity
Mood disorder
Hypertension
Insomnia
Stroke
Heart disease

Click to customize text box label
Seventh Referring Physician Name

First Name*

Last Name*
Seventh Referring Physician Date of Birth*
Seventh Referring Physician Fax number

Referring physician's Office name and location (City, St)

PATIENT'S DEMOGRAPHICS


Full Name

Date of Birth

Phone Number

Email
Does this patient have insurance?*
Yes
No
Unsure

Who is their insurance provider?
DX CODE*
G47.33 OBSTRUCTIVE SLEEP APNEA
Prescribed Services
E0486 CUSTOM ORAL APPLIANCE TO TREAT OSA
HOME SLEEP STUDY
History and Symptoms
Witnessed Apneas
Impaired Cognition
Excessive daytime sleepiness
Loud snoring often interrupted by silence & gasps
Obesity
Mood disorder
Hypertension
Insomnia
Stroke
Heart disease

Click to customize text box label
Eighth Referring Physician Name

First Name*

Last Name*
Eighth Referring Physician Date of Birth*
Eighth Referring Physician Fax number

Referring physician's Office name and location (City, St)

PATIENT'S DEMOGRAPHICS


Full Name

Date of Birth

Phone Number

Email
Does this patient have insurance?*
Yes
No
Unsure

Who is their insurance provider?
DX CODE*
G47.33 OBSTRUCTIVE SLEEP APNEA
Prescribed Services
E0486 CUSTOM ORAL APPLIANCE TO TREAT OSA
HOME SLEEP STUDY
History and Symptoms
Witnessed Apneas
Impaired Cognition
Excessive daytime sleepiness
Loud snoring often interrupted by silence & gasps
Obesity
Mood disorder
Hypertension
Insomnia
Stroke
Heart disease

Click to customize text box label
Ninth Referring Physician Name

First Name*

Last Name*
Ninth Referring Physician Date of Birth*
Ninth Referring Physician Fax number

Referring physician's Office name and location (City, St)

PATIENT'S DEMOGRAPHICS


Full Name

Date of Birth

Phone Number

Email
Does this patient have insurance?*
Yes
No
Unsure

Who is their insurance provider?
DX CODE*
G47.33 OBSTRUCTIVE SLEEP APNEA
Prescribed Services
E0486 CUSTOM ORAL APPLIANCE TO TREAT OSA
HOME SLEEP STUDY
History and Symptoms
Witnessed Apneas
Impaired Cognition
Excessive daytime sleepiness
Loud snoring often interrupted by silence & gasps
Obesity
Mood disorder
Hypertension
Insomnia
Stroke
Heart disease

Click to customize text box label
Tenth Referring Physician Name

First Name*

Last Name*
Tenth Referring Physician Date of Birth*
Tenth Referring Physician Fax number

Referring physician's Office name and location (City, St)

PATIENT'S DEMOGRAPHICS


Full Name

Date of Birth

Phone Number

Email
Does this patient have insurance?*
Yes
No
Unsure

Who is their insurance provider?
DX CODE*
G47.33 OBSTRUCTIVE SLEEP APNEA
Prescribed Services
E0486 CUSTOM ORAL APPLIANCE TO TREAT OSA
HOME SLEEP STUDY
History and Symptoms
Witnessed Apneas
Impaired Cognition
Excessive daytime sleepiness
Loud snoring often interrupted by silence & gasps
Obesity
Mood disorder
Hypertension
Insomnia
Stroke
Heart disease

Click to customize text box label
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Fax number

Referring physician's Office name and location (City, St)

PATIENT'S DEMOGRAPHICS


Full Name

Date of Birth

Phone Number

Email
Does this patient have insurance?*
Yes
No
Unsure

Who is their insurance provider?
DX CODE*
G47.33 OBSTRUCTIVE SLEEP APNEA
Prescribed Services
E0486 CUSTOM ORAL APPLIANCE TO TREAT OSA
HOME SLEEP STUDY
History and Symptoms
Witnessed Apneas
Impaired Cognition
Excessive daytime sleepiness
Loud snoring often interrupted by silence & gasps
Obesity
Mood disorder
Hypertension
Insomnia
Stroke
Heart disease

Click to customize text box label
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.<br><br> I CERTIFY THAT THE ABOVE SERVICES PRESCRIBED BY ME ARE MEDICALLY INDICATED AND IN MY OPINION ARE REASONABLE AND NECESSARY WITH REFERENCE TO ALL PROFESSIONALLY RECOGNIZED MEDICAL STANDARDS AND TREATMENT.


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