Contact 1) Patient form: Welcome!First Name Last Name Patient InformationPrefix First Name Last Name MI Home PhoneCell PhoneWork PhoneThe best time to contact me is: Morning Mid-Day Evening On: Home phone Cell phone Work phone Email* Would you like to receive our e-newsletter? Yes No Address Street Address City State / Province / Region ZIP / Postal Code Date of Birth MM slash DD slash YYYY GenderMaleFemaleOtherPrefer not to saySocial Security Number (SSN) Height:Feet Inches Weight (lbs) Marital StatusMarriedSingleLife PartnerMinorSpouse or Parent/Guardian (if minor) Name Emergency Contact Relationship PhoneREFERRED BY Employer InformationEmployer PhoneFAXAddress City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Health Insurance InformationPatient’s Relationship to Primary Insured:SelftChildSpouseOtherName of Insured (First, MI, Last) Insured DOB MM slash DD slash YYYY Ins Co. Ins ID Group # Plan Name Business Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip PhoneFAXEmail Please present your insurance card so we can photocopy it.Secondary Health Insurance InformationDo you have secondary health insurance? Yes No Medical ContactsDental Sleep Solutions® coordinates treatment with your other medical providers to ensure maximum benefit to you. Where applicable, please list your other medical providers.PRIMARY CARE DOCTOR PhoneENT PhoneSLEEP DOCTOR PhoneDENTIST PhoneOTHER MD PhoneI certify this information is true, accurate, and complete to the best of my knowledge.SignatureDate MM slash DD slash YYYY 2) Physician referral form: Physician Name Physician PhonePatient Name Patient Phone*Please fax copy of patient’s medical insurance with this prescription and Sleep Study.Patient Address Choices Sleep Apnea Simple Snoring Oral Appliance Consultation NotesPhysician Signature Date MM slash DD slash YYYY Upload Sleep StudyMax. file size: 300 MB.