Clinical Intake Process Form

Welcome to Your Journey to Better Sleep!
For safety reasons, we can only treat patients at low risk of side effects or complications. You may be eligible if you:
- Are a new patient
- Are between 18 and 65 years old
- Have no major medical, mental health, or substance use conditions that could make sleep medications unsafe
- Are not pregnant and not planning to become pregnant
Do you meet all the above criteria?*

YesNo, I’m a Returning PatientNo, I would like to become a new patient, but I do not meet one or more of the above criteria.
Due to ethical considerations and liability insurance restrictions, our virtual treatment services are not permitted for patients with these risk factors. However, if you believe your situation involves unique circumstances, please feel free to reach out to us at Admin@SleepScriptMD.com.

Where We Operate: State Eligibility
We’re expanding quickly and are already licensed in over half the U.S.! Check the list below to see if we can serve you. If not, stay tuned—we’ll notify you when we’re available in your state.

Live in an approved state?
Approved States ✅

Arizona

California

Colorado

Connecticut

Delaware

District of Columbia

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

New Hampshire

New Jersey

New York

North Carolina

North Dakota

Ohio

Oklahoma

Pennsylvania

Tennessee

Texas

Utah

Virginia

Washington

West Virginia

Wisconsin

Wyoming
Where do you currently reside?*
⚠ Required Virtual Appointment for Your State

Due to your state’s regulations, your first visit with SleepScriptMD must include a brief video appointment with a licensed provider.
- Cost: $95 (includes the appointment and, if appropriate, a 30-day prescription)
- Length: 5–20 minutes
- Scheduling: Book at the end of this intake — most are available within 2 business days.
After this one-time video visit, most follow-ups can be done asynchronously — no future appointments required unless you request one.
What state are you in?*
If you want us to notify you when we launch in your state, enter your email below.
example@example.com
Great! We are fully licensed to provide quality sleep care in your state. Please continue!

💤 Quick Sleep Safety Check
Before we move forward, we need to rule out certain conditions that require in-person care and cannot be safely treated through SleepScriptMD.
Your answers here will help us determine the right next step — whether that's continuing online or guiding you to the appropriate specialist.

🟡 Sleep Apnea Concerns (Still Eligible for Care)
Have you been told you snore, gasp, or stop breathing during sleep?

NoYes
If you answered “Yes,” we can still help — but you’ll need to complete an at-home sleep test before any treatment can begin.

Medications are not prescribed until your test results are reviewed.

You can continue with this intake form now to get started — most patients begin testing within just a few days.

🚫 Conditions We Cannot Treat Through SleepScriptMD

(These require in-person evaluation by a local-to-you sleep specialist or your primary care provider)
If any of the symptoms below apply to you, you will need an in-person evaluation with a local specialist instead of continuing care through SleepScriptMD.

1. Possible Narcolepsy
- Do you ever fall asleep unexpectedly during the day (e.g., while talking or driving)?
- Do your knees buckle or muscles go weak during strong emotions?
- Do you feel paralyzed when falling asleep or waking up?
These may be signs of narcolepsy, a neurological sleep disorder requiring a full in-person sleep study.

2. REM Sleep Behavior Disorder (RBD)
- Has anyone told you that you move, punch, kick, yell, or act out dreams in your sleep?
  This disorder may be an early warning sign of neurological conditions like Parkinson’s or Lewy Body Dementia. Sleep medications can worsen RBD, and diagnosis requires a video sleep study.
3. Restless Legs Syndrome (RLS)
- Do you feel an uncomfortable urge to move your legs at night or while resting?
  RLS can be linked to iron deficiency, nerve damage, or neurological conditions, and should be evaluated by your local provider before treatment.
Do any of the symptoms above apply to you

No, none applyYes, one of the above applies
Which condition(s) are concerning you?

Narcolepsy symptomsREM Sleep Behavior DisorderRestless Legs Syndrome

Pause Here: Specialist Evaluation Recommended
⚠️ Important Notice
Based on your answers, your symptoms may be consistent with narcolepsy or a related sleep disorder. These conditions require in-person evaluation with a sleep specialist or primary care provider to ensure safe and accurate diagnosis.

Unfortunately, we cannot provide treatment through SleepScriptMD for these concerns — but you’re not alone, and help is available.

To learn more and find support, visit the Narcolepsy Network Resource Center.

We strongly encourage you to follow up locally to begin the right treatment path.

If you selected “Yes” on the previously slide by mistake, just click “Back” to update your answer before moving forward.

Important: In-Person Evaluation Needed for Dream-Enactment Sleep Behaviors
Your response suggests you may be experiencing symptoms of REM Sleep Behavior Disorder (RBD) — a condition that is very different from typical insomnia or anxiety-related sleep issues.

🛌 What is RBD?
During REM sleep, your muscles are normally paralyzed to keep you still while dreaming. In RBD, this paralysis breaks down — leading people to yell, kick, punch, or physically act out their dreams.
This can be dangerous for both you and your bed partner.

⚠️ Why This Matters:
RBD is often a red flag for underlying neurological conditions, especially in older adults. It may be an early warning sign of:
- Parkinson’s disease
- Lewy Body Dementia
- Multiple System Atrophy
💊 Medication Warning:
Common sleep medications — including trazodone, SSRIs, SNRIs, and TCAs — can worsen or unmask RBD symptoms.
For this reason, we cannot safely prescribe sleep medications if RBD is suspected.

📍 What to Do Next:
Please consult a neurologist or a sleep center in your area. Diagnosis typically requires an overnight video sleep study (polysomnography) to confirm RBD.

We’re not able to treat this condition through SleepScriptMD, but identifying it is an important step toward the right care.

If you selected “Yes” on the previously slide by mistake, just click “Back” to update your answer before moving forward.

Important: Rule Out Medical Causes of Restless Legs
Based on your response, you may be experiencing symptoms of Restless Legs Syndrome (RLS). While it’s sometimes benign, RLS can also signal underlying medical conditions that need to be ruled out before treatment begins.

Common causes of RLS include:
- Iron deficiency (with or without anemia)
- Kidney disease or dialysis-related changes
- Peripheral nerve damage (e.g., from diabetes, B12 deficiency, or alcohol use)
- Neurological conditions like Parkinson’s disease or multiple sclerosis
- Medication side effects (from antihistamines, antidepressants, etc.)
💡 What to do next:
Please follow up with your primary care provider or a local specialist to complete basic lab work and evaluation. This may include tests for ferritin, iron, kidney function, B12, and blood sugar.

Treatment through SleepScriptMD is not available for RLS at this time, as it must be addressed in coordination with in-person care to ensure your safety.

If you selected “Yes” on the previously slide by mistake, just click “Back” to update your answer before moving forward.

Choose the Care That’s Right for You
💊 Initial Prescription – $42 Discounted this month to $25!

📦 Includes your first 30-day prescription
🔄 Sent directly to your preferred pharmacy
💵 Note: Medication cost is not included and depends on your pharmacy and insurance.

🔁 Follow-Up Prescriptions

🗓️ $42 for each 30-day refill
💳 $99 for a 90-day subscription (Best Value)
🏷️ Save time and money with extended coverage

If a 10–20 minute virtual intake appointment is needed or preferred due to a medical or mental health concern, the cost is $110. This option will be presented at the end of this intake process if applicable to you.

Addictive Medications Policy
For safety reasons, we do not prescribe certain insomnia medications due to risks like dependency, abuse, or serious side effects. Examples include the following classes:

Demographics
Date

MonthDayYear
Date
Legal Name*

First NameLast Name
Preferred Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Proof of Identity: Please take a selfie with your photo ID next to your face.*

Emergency Contact
Name*
Phone Number*
Please enter a valid phone number.
Relationship to you?*

Personal Health Information
Height (inches)
Weight (lbs)*
Date of Birth (mm/dd/yyyy)*

MonthDayYear
Date
Age Calculattion
Age Calculattion 2
Age
Sex Assigned at Birth*

MaleFemale

We're Sorry — SleepScriptMD Is for Adults Only

Due to ethical and legal regulations, we are unable to provide treatment to individuals under the age of 18 at this time.

If you entered your age incorrectly, you can hit “Back” to update it.

Otherwise, we recommend speaking with a pediatrician or adolescent mental health provider who can offer developmentally appropriate care.

Medical Concerns
Do you have any medical conditions that are currently being treated or may require treatment?

YesNo

Medical Hospitalization History
In the past three years, have you been hospitalized overnight for a medical condition for which you still experience symptoms or are currently receiving treatment?

YesNo
For our records, please briefly describe what you were hospitalized for, what treatment you received during and after, and why treatment is no longer necessary (if it’s not self-explanatory).

0/300

Previous Medications & Supplements
Have you previously taken any prescription medications or supplements for physical or mental health reasons that you’re no longer using?

YesNo
If yes, please list anything you can remember below:
– Name of medication or supplement
– Dose (if known)
– What it was used for
– Why you stopped taking it
Please list here

Current Medications & Supplements
Do you take any prescription medications, over-the-counter medications, or supplements?

YesNo
Please provide more information of any prescription or over-the- counter medications you take.*
In the box below, if you're currently taking any supplements, please include the name, dose, and when you take it each day. Also, briefly note what it's for, whether you feel it's helping, and if you've noticed any side effects.

Drug Allergies
Do you have any known drug allergies?*

YesNo
Please provide more information of any known drug allergies you have.*
If you have had an allergy to a supplement, please list the supplement name and the related reaction below.

Mental Health Concerns
Have you ever received a mental health diagnosis, taken psychiatric medication, or participated in any form of mental health treatment (such as therapy, counseling, or hospitalization) — whether currently or in the past?

YesNo

Recent Psychiatric History
Within the past 2 years (including today): Have you taken any psychiatric medications for mental health conditions other than insomnia (trouble sleeping)? OR Have you had untreated symptoms (like anxiety, depression, mood swings, or focus issues) that you feel should have been treated?

YesNo

Thank you for sharing — and we're truly glad you've sought care recently.

SleepScriptMD is designed for focused, streamlined treatment of insomnia through a largely asynchronous model. When there’s been recent mental health concerns, it’s best to work with a mental health provider who can offer more regular, targeted care beyond just sleep.

If you selected "Yes" by mistake, you can go back and correct your answer below:

🔙 Go Back

Substance Use Concerns
Have you ever experienced issues with substance abuse or dependency related to drugs, alcohol, or medication, excluding nicotine and marijuana?

YesNo

Thank you for your response — and for your openness.
Due to safety considerations and insurance restrictions, we’re unable to provide treatment when there’s a recent history of substance use, especially given the nature of sleep medications. We recommend connecting with a local provider who can offer more specialized and comprehensive support.
- If you selected "yes" in error, please click "Back" to update your response.
- For immediate assistance, we encourage you to reach out to a local addiction specialist or contact the SAMHSA National Helpline at 1-800-662-HELP.

Sleep Assessment Questionnaire
This brief sleep symptoms screening allows us to determine whether our services align with your needs or if your situation requires specialized care from a provider better equipped to address complex sleep concerns. This process ensures we maintain the highest standards of treatment and comply with our commitment to quality and responsible care.
How would you describe your sleep?*

I have trouble sleeping and/or often feel tiredI sleep well and feel rested
We’re happy to hear you’re already sleeping well! Since we specialize in treating insomnia, we cannot provide treatment at this time.

Sleep Issues
What sleep issues do you experience? (Check all that apply)*

Trouble falling asleepWaking up during the nightWaking up too early and can’t fall back asleepRestless Sleep

Average Sleep Duration
How many hours of sleep do you usually get per night?*

Less than 5 hours5–7 hoursMore than 7 hours

Choose Your Sleep Intervention
(You can choose only one option below, but all options include free access to our Sleep Hygiene Guide.)*

Sleep Medication Prescription Explore safe, non-addictive prescription options to help with insomnia. We’ll show you a few choices in the next slides, each with pros and cons.At-Home Sleep Study I’d prefer to start with testing before considering medications. Please send me an at-home sleep study that will be interpreted by a board-certified sleep specialist.Supplement Ideas for Sleep Receive non-prescription, physician-recommended options tailored to your sleep patterns.None of the Above — Just Interested in Sleep Hygiene Tips (Free!) No problem. You’ll still get access to our expert-backed tips to improve your sleep naturally.

🌿 Your Natural Sleep Support Plan
Thanks for your interest in non-prescription options to improve your sleep!

✨ We’ve put together a curated list of physician-recommended supplements based on your sleep patterns and concerns.
🔗 Explore your personalized recommendations here:
DrDavidDanish.com/SupplementsForSleep

🛏️ Plus: Get Your Free Sleep Hygiene Guide
📘 Along with your supplement suggestions, we’ll also send you our expert-backed Sleep Hygiene Guide — full of practical tips to help you sleep better, naturally.
📩 Should we use the email address you already provided to send it?

YesNo, I’d like to enter a different email
Email
example@example.com

Get Your Free Sleep Hygiene Guide
We’re glad you’re interested in improving your sleep naturally — and we’ve got you covered.

📘 Our expert-backed Sleep Hygiene Guide includes practical tips to help you fall asleep faster, stay asleep longer, and wake up more refreshed.
📩 Should we use the email address you already provided to send it?

YesNo, I’d like to enter a different email
Email
example@example.com

Choosing Your First Sleep Medication
Based on your sleep concerns, we offer three first-line medications known to help with sleep. To ensure safe and effective treatment, one of these must be tried before considering other options.

Click on a medication below to learn about its benefits, dosing, and potential side effects. You can only proceed after selecting one.

If you have already tried all three, select the last option to schedule a required virtual appointment for further evaluation.
Choose Your Medications*

ClonidineHydroxyzine (Vistaril)TrazodoneI have tried all three (in which case you must do a virtual appointment, which you can schedule upon completion of this clinical intake form)
Clonidine

Brand Name: Catapres
Available Doses: Immediate-release tablets: 0.1 mg, 0.2 mg, and 0.3 mg

Minimum / Maximum Dose: 0.05 - 0.3 mg nightly

What is Clonidine?
Clonidine is a centrally acting alpha-2 adrenergic agonist that was originally developed to lower blood pressure. Over time, its off-label uses have expanded significantly. It is now frequently prescribed to manage insomnia, anxiety, ADHD, and even opioid withdrawal symptoms. By reducing sympathetic nervous system activity, clonidine induces a calming, sedative effect, which makes it effective for sleep.

Additionally, clonidine is used in some cases for post-traumatic stress disorder (PTSD), tics (Tourette’s syndrome), and hot flashes related to menopause. Emerging research also explores its role in mitigating inflammatory responses, making it a topic of interest in conditions like Long COVID.

The Doctors’ Insights
In clinical practice, clonidine is an effective and underutilized sleep aid, especially for individuals who struggle with racing thoughts, stress-related insomnia, or ADHD-related sleep disturbances. It works quickly, helping patients fall asleep within 30 to 60 minutes without the risk of addiction or tolerance buildup.

Unlike some sedative medications, clonidine rarely causes morning grogginess because it lacks the lingering effects of drugs like trazodone or certain antihistamines. However, it is not ideal for everyone. Some individuals experience dizziness, dry mouth, or mild next-day fatigue, especially at higher doses.

For those with ADHD, clonidine provides additional benefits beyond sleep, including reduced hyperactivity, improved impulse control, and decreased emotional reactivity. Because of its blood pressure-lowering properties, it is not recommended for patients prone to dizziness or fainting unless closely monitored.

Pros:
- Non-addictive with no risk of misuse.
- Sedative properties can aid in falling asleep, especially for individuals with ADHD or anxiety related insomnia.
- Available in multiple forms (tablet, patch).
Cons:
- Common side effects include dry mouth, dizziness, fatigue, and constipation.
- Abrupt discontinuation of high doses taken multiple times per day (which is not how we prescribe it) can result in withdrawal symptoms, such as rebound hypertension.
- It can occasionally cause low blood pressure. Therefore, caution is advised for patients with naturally low blood pressure, a tendency to feel dizzy upon standing suddenly, or a history of fainting (syncope).
All Side Effects

Medications to Avoid with Clonidine
Certain drugs can increase side effects or pose risks when combined with clonidine:
- Other blood pressure medications → Risk of excessively low blood pressure (hypotension)
- Sedatives and sleep aids → Increased drowsiness (benzodiazepines, alcohol, antihistamines, opioids)
- Stimulants (ADHD meds like Adderall, Ritalin) → Can cause blood pressure fluctuations when combined
- Beta-blockers → Risk of severe blood pressure drops if clonidine is stopped suddenly
Always consult your provider before combining clonidine with other medications.
Clonidine

Brand Name: Catapres
Available Doses: Immediate-release tablets: 0.1 mg, 0.2 mg, and 0.3 mg

Minimum / Maximum Dose: 0.05 - 0.3 mg nightly

What is Clonidine?
Clonidine is a centrally acting alpha-2 adrenergic agonist that was originally developed to lower blood pressure. Over time, its off-label uses have expanded significantly. It is now frequently prescribed to manage insomnia, anxiety, ADHD, and even opioid withdrawal symptoms. By reducing sympathetic nervous system activity, clonidine induces a calming, sedative effect, which makes it effective for sleep.

Additionally, clonidine is used in some cases for post-traumatic stress disorder (PTSD), tics (Tourette’s syndrome), and hot flashes related to menopause. Emerging research also explores its role in mitigating inflammatory responses, making it a topic of interest in conditions like Long COVID.

The Doctors’ Insights
In clinical practice, clonidine is an effective and underutilized sleep aid, especially for individuals who struggle with racing thoughts, stress-related insomnia, or ADHD-related sleep disturbances. It works quickly, helping patients fall asleep within 30 to 60 minutes without the risk of addiction or tolerance buildup.

Unlike some sedative medications, clonidine rarely causes morning grogginess because it lacks the lingering effects of drugs like trazodone or certain antihistamines. However, it is not ideal for everyone. Some individuals experience dizziness, dry mouth, or mild next-day fatigue, especially at higher doses.

For those with ADHD, clonidine provides additional benefits beyond sleep, including reduced hyperactivity, improved impulse control, and decreased emotional reactivity. Because of its blood pressure-lowering properties, it is not recommended for patients prone to dizziness or fainting unless closely monitored.

Pros:
- Non-addictive with no risk of misuse.
- Sedative properties can aid in falling asleep, especially for individuals with ADHD or anxiety related insomnia.
- Available in multiple forms (tablet, patch).
Cons:
- Common side effects include dry mouth, dizziness, fatigue, and constipation.
- Abrupt discontinuation of high doses taken multiple times per day (which is not how we prescribe it) can result in withdrawal symptoms, such as rebound hypertension.
- It can occasionally cause low blood pressure. Therefore, caution is advised for patients with naturally low blood pressure, a tendency to feel dizzy upon standing suddenly, or a history of fainting (syncope).
All Side Effects

Medications to Avoid with Clonidine
Certain drugs can increase side effects or pose risks when combined with clonidine:
- Other blood pressure medications → Risk of excessively low blood pressure (hypotension)
- Sedatives and sleep aids → Increased drowsiness (benzodiazepines, alcohol, antihistamines, opioids)
- Stimulants (ADHD meds like Adderall, Ritalin) → Can cause blood pressure fluctuations when combined
- Beta-blockers → Risk of severe blood pressure drops if clonidine is stopped suddenly
Always consult your provider before combining clonidine with other medications.
Hydroxyzine

Brand Name: Vistaril

Available Doses: 25 mg and 50 mg capsules or tablets.
Minimum / Maximum Dose: 25 - 100 mg at bedtime.

What is Hydroxyzine?
Hydroxyzine is an antihistamine commonly prescribed for its calming and sedative effects. It is used to treat anxiety, insomnia, itching from allergies, nausea, and even mild pain relief. It works by reducing central nervous system activity and blocking histamine, which causes allergic reactions. Unlike benzodiazepines, hydroxyzine is non-addictive and does not lead to dependence, making it a safer option for long-term use.

The Doctors’ Insights
Hydroxyzine is a versatile medication that effectively helps both falling asleep and staying asleep. It is particularly useful for individuals who struggle with anxiety-related insomnia, as it promotes relaxation without the risk of dependence seen with other sleep aids.

One of the key benefits of hydroxyzine is its fast-acting sedative effect, making it a reliable option for those who have difficulty initiating sleep. Additionally, it helps maintain sleep by reducing nighttime awakenings. Unlike some stronger medications, it does not disrupt normal sleep cycles, allowing for a more natural rest.

However, about 10% of patients report mild morning tiredness as the medication gradually leaves their system. This effect is typically dose-dependent and can often be minimized by adjusting the dosage or taking it earlier in the evening. When used correctly, hydroxyzine provides a safe, non-addictive alternative for improving sleep quality.

Pros and Cons of Hydroxyzine

Pros:

✔ Non-addictive with no risk of dependence.
✔ Fast-acting sedative effects help with sleep onset.
✔ Available as a low-cost generic option.
✔ Versatile uses (anxiety, allergies, nausea, insomnia).

Cons:
✖ Can cause significant drowsiness, dizziness, and dry mouth.
✖ Not suitable for individuals with long QT syndrome or during pregnancy.
✖ May lead to confusion or oversedation in older adults.

Medications to Avoid with Hydroxyzine
Some medications can interact with hydroxyzine, increasing the risk of side effects or adverse reactions:
- Central nervous system depressants (risk of excessive drowsiness): Benzodiazepines, opioids, alcohol, sleep aids.
- QT-prolonging drugs (risk of heart arrhythmias): Certain antibiotics, antipsychotics, antiarrhythmic.
- Antihistamines (risk of enhanced side effects): Diphenhydramine, promethazine.
- CYP3A4 inhibitors (may increase hydroxyzine levels): Some antifungals, antibiotics, HIV medications.
Always inform your provider about your medications to avoid potential interactions.

Common Effects:
✔ Mild relaxation and drowsiness.
✔ Reduction in nighttime awakenings.
✔ Potential morning grogginess, usually improving over time.

Uncommon Effects:
✖ About 5% of patients report mild confusion or dizziness.
✖ Rare cases of dry mouth, headache, or nausea.
✖ If side effects occur, notify your provider for adjustments.

View All Side Effects Here

Medication Information & Consent

Below is detailed information on your medication’s benefits, dosing, and potential side effects. Review it carefully, and if you have further questions, you can set up a virtual intake appointment at the end of the clinical survey.
Signature*

Clear

Pharmacy Information
Pharmacy Name*
💊 You’ll pay for your medication separately at your chosen pharmacy.

💰 No insurance? Check GoodRx.com for big discounts. Enter your zip code + medication to compare local pharmacy prices, then add your preferred pharmacy’s phone number below.
Pharmacy Phone*
Please enter a valid phone number.

SleepScriptMD Patient Agreement: Treatment, Privacy, and Financial Policies
Before receiving care at SleepScriptMD, you must review and agree to this patient agreement. It outlines your rights, treatment policies, financial responsibilities, and privacy protections. Please read carefully—your signature below confirms your consent to treatment and acknowledgment of all policies.
Sign:

Clear

Email Preference
Important Next Steps for Your Prescription

We are about done! Before you submit payment to finalize your prescription, please review the following:
How would you like to receive your medication instructions?

Send to the email address I provided earlierSend to a new email
Enter your Email:*
example@example.com

Thanks for completing your screening.

Based on one or more of your responses related to your medical, mental health, or substance use history, a licensed medical provider will take a closer look at your chart to determine whether AI-assisted asynchronous care is the safest and most appropriate option for you.

Here’s what may happen next:
- Immediate Prescription – If no significant risks are identified, we may still be able to prescribe within 1 business day.
- Virtual Appointment Needed – If your chart suggests a need for further evaluation, we may recommend a brief 10–20 minute virtual visit ($110), usually available within 3 days.
- Unable to Prescribe – If the risks are too high, we may not be able to provide treatment—but we’ll explain why and point you toward safer alternatives if possible.
On the next screen, you’ll be able to choose between synchronous (live) or asynchronous (AI-assisted) care. We’ll take it from there.

Final Step: Confirm & Pay
You're all done with your sleep evaluation! 🎉

Next, one of our licensed medical practitioners will carefully review your information to make sure everything is accurate and appropriate.
If approved, your prescription will be sent to your preferred pharmacy within 1 business day — no phone call required.

This one-time payment includes:

✔️ A thorough asynchronous medical review to ensure the medication is safe and appropriate for you
✔️ Processing and electronic delivery of your prescription to your pharmacy

💡 Note: The fee does not include the cost of the medication itself.

Choose Your Preferred Treatment Approach

💊 Your First 30-Day Prescription: Just $25(Limited-Time Offer – Save Over 40%! Regular monthly fee is $42)

$25.00

🤝 Prefer to Speak With Someone First?Choose a 10–20 minute virtual intake appointment for $110 instead. A provider will walk you through everything in real time.

$110.00

Enter coupon

Total

$0.00

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Cancellation Agreement: By checking "I agree" below, you acknowledge and accept our strict cancellation policy. If you need to cancel or reschedule your appointment, you must notify our office at least 2 full business days in advance (please note that weekends do not count as business days). Failure to provide sufficient notice will result in being charged the full price of the consultation, as time is specifically set aside for you with our Medical Practitioners, which represents a significant cost to our practice.*

I agree
Should be Empty:

Welcome to Your Journey to Better Sleep!

Where We Operate: State Eligibility

Approved States ✅

💤 Quick Sleep Safety Check

🟡 Sleep Apnea Concerns (Still Eligible for Care)

🚫 Conditions We Cannot Treat Through SleepScriptMD

Pause Here: Specialist Evaluation Recommended

Important: In-Person Evaluation Needed for Dream-Enactment Sleep Behaviors

Important: Rule Out Medical Causes of Restless Legs

Choose the Care That’s Right for You

Addictive Medications Policy

Demographics

Emergency Contact

Personal Health Information

Medical Concerns

Medical Hospitalization History

Previous Medications & Supplements

Current Medications & Supplements

Drug Allergies

Mental Health Concerns

Mental Health History

Recent Psychiatric History

Substance Use Concerns

Sleep Assessment Questionnaire

Sleep Issues

Average Sleep Duration

Choose Your Sleep Intervention

🌿 Your Natural Sleep Support Plan

Get Your Free Sleep Hygiene Guide

Choosing Your First Sleep Medication

Pharmacy Information

SleepScriptMD Patient Agreement: Treatment, Privacy, and Financial Policies

Email Preference

Final Step: Confirm & Pay