TSF Sleep Apnea Application
Full Name
*
First Name
Last Name
What is your age?
*
What is your gender?
*
Please Select
Male
Female
N/A
Contact Number
*
Email Address
example@example.com
Dental Insurance Provider?
*
-
Group#
Member ID
Medical Insurance Provider
*
-
Group#
Member ID
Check the conditions that apply to you.
*
Snore
Tired
Obstruction
Other
On average how many hours do you sleep?
*
1-4
4-6
6-8
8+
How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:
Please Select
Would never doze
Slight chance of dozing
moderate chance of dozing
high chance of dozing
How fast would you like treatment?
*
Asap
1-4 Months
Just looking at my options
I have a few questions
Submit
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