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7030 Village Center Drive, Austin, TX 78731

Phone (512) 637-2591


1) Patient form:
  • Welcome!

  • Patient Information

  • MM slash DD slash YYYY
  • Height:
  • Employer Information

  • Health Insurance Information

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  • Please present your insurance card so we can photocopy it.
  • Secondary Health Insurance Information

  • Medical Contacts

    Dental Sleep Solutions® coordinates treatment with your other medical providers to ensure maximum benefit to you. Where applicable, please list your other medical providers.
  • I certify this information is true, accurate, and complete to the best of my knowledge.

  • MM slash DD slash YYYY
2) Physician referral form:
  • *Please fax copy of patient’s medical insurance with this prescription and Sleep Study.
  • MM slash DD slash YYYY
  • Max. file size: 300 MB.