Name
*
First Name
Last Name
Email
*
example@example.com
Mobile Phone Number
*
Please enter a valid phone number.
Have you tried a CPAP?
*
Yes
No
Please answer the following questions by checking if the answer is 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 currently use a CPAP machine?
Do you have medical insurance?
Have you had a sleep study within the last year?
*
Yes
No
What was the date of your last sleep test?
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
*
If you have ever undergone a sleep study, please indicate the severity level of the condition
Anything else we should know?
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!
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