Patient Information
This information will be sent to your provider and will be kept as part of your patient records.
Please complete the form below. We will text you to learn more and schedule a short phone call appointment with us. During this call we can answer any additional questions you may have!
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your legal gender or the gender listed with your insurance carrier?
*
Female
Male
Have you ever been tested for sleep apnea before or taken a sleep test?
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Yes
No
Did a doctor refer you to our practice?
*
Yes
No
Who is your medical insurance provider
*
Please Select
Aetna
United Health Care
Cigna
Blue Cross of TX
Blue Cross of another state
Blue Cross Federal Blue Cross Anthem
Blue Cross Blue Choice
Blue Cross Regence
Medicare Advantage
Medicare A&B
Medicare A&B with supplemental
Tricare
Humana
Other
I don't have medical insurance
If you chose "other" above, what is the name of your medical insurance provider?
What is your Member/Subscriber ID for your insurance so we can check your benefits?
*
Do you have VA benefits?
*
Yes
No
Are you a DOT driver or trying to get tested for work?
*
Yes
No
Please answer the following questions by checking if answer is YES.
*
Do you snore?
Do you often feel tired during daytime?
Has anyone observed that you stop breathing or choke or gasp during your sleep?
Do you have or are you being treated for High Blood Pressure?
Have you ever had a stroke or a heart attack?
Do you have difficulty falling asleep or suffer from insomnia
Do you wake up with morning headaches?
Do you find it difficult to concentrate?
Do you get up in the middle of the night to use the bathroom?
Do you struggle with anxiety or depression?
Your Height
Your Weight
Help us Get to Know You
*
Pick a time below for our office to call you to discuss your symptoms, and schedule your 1st office visit
Choose a date below to schedule a FREE 30 min call back appointment. During this PHONE CALL we will review your results and answer any questions you may have!
*
Please verify that you are human
*
Submit
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