Comprehensive Sleep Disorders Institute and Respiratory Disorders Center

REFERRAL FORM

Patient Information

NAME SEX M F

STREET ADDRESS APT.

CITY STATE

ZIP CODE PHONE NUMBER

EMAIL DATE OF BIRTH

INSURANCE (1)

ID# GROUP

SUBSCRIBER

RELATION TO PATIENT

INSURANCE (2)

ID# GROUP

SUBSCRIBER

RELATION TO PATIENT

Referring Physician

MD NAME

MD OFFICE ADDRESS

CITY STATE

ZIP CODE OFFICE PHONE NUMBER

FAX NUMBER

EMAIL

Clinical History and Indications

History

Excessive daytime somnolence

Witnessed apneic episodes

Early morning headache

Cardiovascular disease

Previous sleep study YES NO

Heavy snoring

Obesity/recent weight gain

Hypertension

Medications:

Comments:

Physical Exam:

WEIGHT: HEIGHT:

BLOOD PRESSURE_/_:

Crowded Oropharynx

Enlarged or soft Palate/ Uvula

Tonsilar hypertrophy

Other Significant Findings:

Tests Ordered:

Consultation and Treatment:

PSG (95810)

MSLT/MWT(95805)

CPAP/Bilevel Tritration(95811)

SPLIT(95811)

VPAP Adapt SV Study (95811)

CPAP/BiPAP If medically Necessary

Other

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