Appointment / Consultation request
Full Name:
*
First Name
Last Name
Are you already a patient of The Sleep Spot Maimonides?
*
Yes
No
I don't know
Requested service:
*
Sleep Study
Clinical Consultation
Patient Mask Appointment (equipment/mask issues)
Sleep Therapy Effectiveness Program (STEP)
I would like to learn more about treatment options - please call me back
Other
Phone Number:
*
Please enter a valid phone number.
Email:
*
example@example.com
Date of birth:
*
-
Month
-
Day
Year
Date
Primary Insurance:
*
Insurance Number:
*
Preferred appointment date:
-
Month
-
Day
Year
Date
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Consent to Receive Phone Text (SMS) messages
*
By providing my mobile phone number I consent to receive SMS messages (including text messages), and telephone calls from Maimonides Sleep Arts & Sciences Ltd., dba The Sleep Spot - Maimonides, its agents, representatives, affiliates, or anyone communicating on their behalf at the specific number I have provided. I certify, warrant, and represent that the telephone number I have provided is my contact number and not someone else’s. I represent that I am permitted to receive calls and text messages at the telephone number I have provided. I agree to promptly alert The Sleep Spot whenever I stop using this telephone number. I understand standard message and data rates may apply to all SMS messages (including text messages). I understand I may opt-out of receiving text (SMS) messages from the Sleep Spot or its business partners at any time by replying with the word STOP from the mobile device receiving the messages.
Submit
Should be Empty: