Name
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First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Mobile Phone Number
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Please enter a valid phone number.
Email
*
example@example.com
Do you have Medical Insurance? (note: we do not accept medicaid, medicare, or UnitedHealthcare)
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Regence
MODA
Cigna
Other
No medical insurance
Please answer the following questions by checking if answer YES.
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Do you snore?
Do you often feel tired, fatigued, or sleepy 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?
Is your age over 50 years old?
Is your neck size larger than 15" (Females) or 16.5" (Males)?
Your Weight
Your Height
What is your legal gender or the gender listed with your insurance carrier?
Female
Male
Choose a date below to schedule a FREE 20 min learn more phone call. On this call we will answer any questions you may have, and schedule your first visit!
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