Appointment / Consultation request
Full Name:
*
First Name
Last Name
Date of birth:
*
-
Month
-
Day
Year
Date
Phone Number:
*
Please enter a valid phone number.
Email:
*
example@example.com
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
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: