Step 1: Adult Home Sleep Study Initial Contact Form

Adult Home Sleep Study

Please fill in these quick questions so we can find out more about you and what type of sleep study service you need. Submit your details and Aer's friendly staff will contact you or you can get started straight away. Don't worry if you get lost, we will contact you if we see that you need help.
Name*

First NameLast Name
Mobile Phone Number*
Please enter a valid mobile phone number so we can remind you when your sleep study is coming and when you have to return it.
Email*
If this email is not correct, you will not receive the report
Date of birth*

DayMonthYear
Date
How did you find out about our service?*

My dentistMy orthodontist or specialist dentistMy GP or specialist medical doctor (not my specialist dentist)Other professionalI have no recommending professional
Please provide further details about your dentist, so we can keep them informed of your progress
Dentist's name:*
Dental clinic's name:*
Dental clinic's email address:*
If this email is not correct, your dentist will not receive the report
Please provide further details about your orthodontist or specialist dentist, so we can keep them informed of your progress
Orthodontist or specialist dentist's name:*
Orthodontist or specialist clinic's name:*
Orthodontist or specialist clinic's email address:*
If this email is not correct, your orthodontist will not receive the report
Please provide further details about your GP or specialist medical doctor, so we can keep them informed of your progress
GP or specialist medical doctor's name:*
GP or specialist medical clinic's name:*
I
GP or specialist medical clinic's email address:*
If this email is not correct, your GP will not receive the report
Please provide further details of the professional that recomended you to us, so we can keep them informed of your progress
Professional's name:*
Professional clinic's name:*
Professional clinic's email address:*
If this email is not correct, your recommending professional will not receive the report
Do you have a Medicare card?*

YesNo
Does your Medicare card say 'Reciprocal Health Care'?*

No, it does notYes, it does
Have you had a home sleep study in the last 12 months?*

No, I have notYes, I have
When you submit this form, you can start filling in the sleep test at home information we need from you.

If you don't have time to start right now, you will receive the link as a text message so you can find it later.
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