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Referring Doctors

You may refer patients to Surgical Sleep Solutions by filling out our patient evaluation/referral form below. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.

At the end of the evaluation you will be provided the option to forward the information to Surgical Sleep Solutions for follow-up consultation after entering doctor and patient demographics. From there we will contact the patient to gather remaining patient information as needed and set up a consultation.

Please read our Privacy Policy and our HIPAA Privacy Policy if you have any further questions.

Referring Doctor Form

Patient Information

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

Referring Doctor Information

Referring Doctor *

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