New Customer Registration Form

Physician Order Form
Two practitioner order options exist.

Patient-pay:

The provider places the order, and we will bill your patient $289 for the service. This is the most popular billing option. To use this option simply select the “Bill Patient” checkbox below.

Practitioner-pay:

The provider places the order, pays upfront for the service and then bills the patient. We recommend charging $289. If you select this option, we will contact your office, upon your first order, to discuss pricing and to set up payment. We will maintain your payment information for future orders and will not need to contact your office for each new order. To choose this option select the “Bill Provider” checkbox below.
Patient Information
Full Name*

First NameLast Name
Date of Birth*
Guardian Name *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian Phone Number*
*This will only be used if you select the Bill Patient Option.
E-mail
example@example.com
Prescriber Information
Ordering Provider Name*

First NameLast Name
Specialty*
Office E-mail*
example@example.com
Office Phone*
Office Fax*
Office Manager*
REASON FOR STUDY

Loud SnoringBedtime ResistanceChoking/GaspingDaytime SleepinessObserved ApneaMood/Behavior ProblemsAttention/ADHD ProblemsBed WettingMorning Headaches
RISK FACTORS

Obesity/BMIAdenotonsillar HypertrophyAllergiesBehavior ProblemsADHDGERDNight SweatingNight TerrorsAcademic Problems
Other:
BILLING*

Bill Patient For This ServiceBill Provider For This Service
Ordering Provider Signature*

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Physician Order Form