Name
*
First Name
Last Name
Email
*
example@example.com
Mobile Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Please answer the following questions by checking if answer YES.
*
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)?
Do you currently use a CPAP machine?
Do you have medical insurance?
Gender
*
Female
Male
Prefer not to answer
Your Weight
*
Your Height
*
Have you had a sleep study within the last year?
*
Yes
No
What was the date of your last sleep test?
If you have ever undergone a sleep study, please indicate the severity level of the condition
Do you have medical insurance?
*
Yes
No
If you have medical insurance, please specify the name of your insurance provider. Write "N/A" if you do not have medical insurance.
*
Do you wear a complete upper or lower denture?
*
Do you have a current dentist?
Yes
No
When was your last dental check up
*
Choose a date below to schedule a FREE 15 min call back appointment. We will call you at the time you choose below and answer any questions you have!
*
Submit
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