Member Introduction

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How can we help you today?
I am interested in improving my sleep
I am a healthcare provider and I want to implement Empower Sleep in my practice
Other
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UniqueID
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What is your name?
First Name
Last Name
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What is your email address?
example@example.com
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Which of the following best describes your main wellness or health goal?This will help us to tailor the treatment plan for your needs
I want to improve my quality of sleep
I want to improve my quality of life
I want to live a longer & healthier life
I want to improve my mental health
I am managing a chronic health condition (cardiac health, hormonal health, diabetes, etc.)
I want to increase physical and/or mental performance
I want to reduce disruptions for my bed partner
Other
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Have you been previously diagnosed with a sleep condition?This will help us to tailor the treatment plan for your needs
I have been diagnosed with sleep apnea
I have been diagnosed with insomnia
I have been diagnosed with Restless Legs Syndrome (RLS)
I have never been diagnosed
Other
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Which of the following best describes the objective for you first visit?This will help us to tailor the treatment plan for your needs
I am would like to learn how to improve my sleep
I am looking to consult an Empower Sleep sleep physician
I am looking for a comprehensive treatment
I am looking for an at home sleep test
I am looking for help with a specific sleep aid (CPAP, dental appliance, medication, etc)
Other
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Which state do you currently live in?* This field is required.
Alabama
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Other
Pennsylvania
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South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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How can we help guide you towards better sleep?* This field is required.This will help us build a comprehensive plan to get your sleep back on track
I am looking for educational materials to improve my sleep
I need continuous sleep guidance from a board-certified sleep physician
I would like to treat my insomnia
I would like to eliminate snoring and/or prevent sleep apnea
I would like an FDA-approved sleep test to understand my sleep quality
Other
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What is your date of birth?* This field is required.Please enter in the format MM/DD/YYYY
Enter in the format MM/DD/YYYY
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How did you find out about Empower Sleep?* This field is required.
Insurance Website
Dentist
Doctor
Google search
Instagram
Facebook
Friend/colleague
LinkedIn
Podcast
Other
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Who is the doctor/dentist that referred you?
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What is the clinic name?
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Wonderful! Who can we thank for referring you?
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Empower Sleep: A Personalized Sleep Care ExperienceTraditional sleep care relies on one night of sleep data to make decisions, which fails to capture trends and often results in cookie-cutter treatment. Empower Sleep is an innovative way of delivering comprehensive sleep care. Our providers use continuous sleep testing to understand your sleep trends, allowing them to provide an unparalleled level of personalized care with much better outcomes. Here's an introduction to how it works:
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Empower Sleep MembershipEmpower Sleep is an innovative way of delivering comprehensive sleep care. Our providers use continuous sleep testing to understand your sleep trends, allowing them to provide an unparalleled level of personalized care with much better outcomes. Telemedicine consults are paid out of pocket or billed to your insurance separately from the membership fee.
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Check below to agree to our Privacy Policy, Terms & Conditions, and Telemedicine Consent.* This field is required.
I agree
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What is your phone number?* This field is required.
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Gender
Female
Male
Other
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Which option do you prefer for your physician visits?* This field is required.We will verify your insurance benefits to expedite your care
I would like to pay for clinician visits out-of-pocket
I would like to use my insurance
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How would you like to pay? Calculated
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What is your address associated with your insurance? This will help us verify your benefits swiftly..All information will remain confidential
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
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Country
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Upload a picture of your insurance card (front).* This field is required.We will run your benefits and get back to you
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Upload a picture of your insurance card (back).* This field is required.We will run your benefits and get back to you
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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When we verify your insurance, we will reach out to schedule your visit. How would you like for us to communicate with you?* This field is required.
Schedule time with a clinical coordinator now
Have a coordinator call me whenever my benefits are verified
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Let's start with step 1: Schedule time with a clinical coordinator to learn more* This field is required.We're excited to meet you!
Schedule time with a clinical coordinator to learn more!
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