Medical/Dental Referrals

1

Referring Practitioner Name* This field is required.

First Name

Last Name

2

Clinic / Practice Name* This field is required.

3

Referring Practitioner Email* This field is required.

example@example.com

4

Referring Practitioner Phone* This field is required.

Please enter a valid phone number.

5

Patient Name* This field is required.

First Name

Last Name

6

Caregiver/Guardian Name (if applicable)

First Name

Last Name

7

Patient/Caregiver Preferred Language* This field is required.

8

Patient Date of Birth* This field is required.

Date

9

Patient Province* This field is required.

10

Patient/Caregiver Email:* This field is required.

example@example.com

11

Patient/Caregiver Phone #:* This field is required.

Please enter a valid phone number.

12

Patient Consent* This field is required.

I confirm the patient (or their parent/caregiver) has consented to this referral to NaviSleep.

13

Reason for Referral (Adult): Please check all that apply

Snoring or breathing concerns during sleep

Daytime fatigue, low energy, or brain fog

Non-restorative or poor-quality sleep

Insomnia or frequent awakenings

Teeth grinding, mouth breathing, or dry mouth

Previously diagnosed with sleep apnea

CPAP intolerance or optimization needed

Perimenopause / Midlife Sleep Changes

Other

14

Reason for Referral (Pediatric): Please check all that apply

Snoring or breathing concerns during sleep

Witnessed pauses in breathing, gasping, or choking during sleep

Night sweats/restlessness/non-restorative or poor-quality sleep

Enlarged tonsils/adenoids

Teeth grinding, mouth breathing, or dry mouth

Bedwetting

Hyperactivity, inattention, or behavioral concerns

Night terrors

Other

15

Additional Clinical Observations (optional)

16

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