Referral For Sleep Evaluation And Treatment
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1Referral for Sleep Evaluation
and Treatment
Patients:
Please go to , click on the
Patient Portal to complete your registration. Thanks!
Patient Information
Name
DOB
q Male
q Female
Address
City
State
Zip
Primary Phone
Alternate Phone
Primary Insurance Provder
Patient E-mail
Policy #
Group #
Secondary Insurance
Policy #
Group #
Emergency Contact
Phone
Relationship
Referral Information
S
Snores loudly?
Y
N
Purpose of Referral
q Snoring
T
Tired in the daytime?
Y
N
q Insomnia
O
q Excessive daytime sleepiness
Someone observed patient stop breathing?
Y
N
q Restless legs syndrome
P
q CPAP follow up
High blood pressure?
Y
N
q Pre-surgical evaluation
q Patient request
B
BMI more than 35 kg/m2?
Y
N
q Hypoxemia
q Other:
A
Age over 50 years?
Y
N
Other considerations
N
Neck circumference greater than 16 in?
Y
N
q Spanish-speaking patient
G
q Out-of-town patient
Gender male?
Y
N
q Other:
High Risk of Obstructive Sleep Apnea: Yes to 3 or more items
Referring Provider Information
Name
Practice
Phone
Fax
Signature
Providers: Please give a copy of this form to the patient.
OmniSleep Medicine Centers
6500 Jefferson Street NE, Suite 100 Albuquerque, NM 87109
Phone: (505) 843-8758 Fax: (505) 843-8759
9am-5pm Mon. - Fri.
Fax this referral to (505) 843-8759 or the alternate (505) 243-8338.
or email this referral to referrals@
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Parent category: Business