Patient Forms - Sleep Apnea - Sleep Apnea Form

Welcome!

First Name

Last Name

Patient Information

Prefix

First Name

Last Name

MI

Home Phone

Cell Phone

Work Phone

The 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

Gender

Social Security Number (SSN)

Height:

Feet

Inches

Weight (lbs)

Marital Status

Spouse or Parent/Guardian (if minor) Name

Emergency Contact

Relationship

Phone

REFERRED BY

Employer Information

Employer

Phone

FAX

Address

City

State

Zip

Health Insurance Information

Patient’s Relationship to Primary Insured:

Name of Insured (First, MI, Last)

Insured DOB

Ins Co.

Ins ID

Group #

Plan Name

Business Address

City

State

Zip

Phone

FAX

Email

Please present your insurance card so we can photocopy it.

Secondary Health Insurance Information

Do you have secondary health insurance?

Yes
No

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.

PRIMARY CARE DOCTOR

Phone

ENT

Phone

SLEEP DOCTOR

Phone

DENTIST

Phone

OTHER MD

Phone

I certify this information is true, accurate, and complete to the best of my knowledge.

Signature

Date

Patient form

Welcome!

Patient Information

Employer Information

Health Insurance Information

Secondary Health Insurance Information

Medical Contacts

I certify this information is true, accurate, and complete to the best of my knowledge.