Referring Doctor Form

Patient Information
Patient Name
Patient Address
Patient Medical Information
Does patient snore? 
Has their snoring ever bothered other people? 
Does patient have high blood pressure? 
Has anyone noticed that they quit breathing during sleep? 
How often does patient snore? 
How often do they feel tired or fatigued after sleep? 
During waking time, do they feel tired, fatigued or not up to par?  
Has patient had sleep study? 
Has patient tried using CPAP? 
Referring Doctor Information
Referring Doctor
33%

Looking to refer your patient to
Surgical Sleep Solutions?

You can refer patients to Surgical Sleep Solutions by completing the patient evaluation/referral form provided on this page. We prioritize the security and confidentiality of patient information, employing stringent measures to safeguard it.

Upon completing the evaluation, you’ll have the opportunity to send the information directly to Surgical Sleep Solutions for a follow-up consultation. This requires entering the demographics of both the doctor and the patient. Following this, our team will reach out to the patient to collect any additional necessary information and arrange a consultation.

For any questions regarding how we protect patient data, please review our Privacy Policy and our HIPAA Privacy Policy.

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