Test Type
Baseline Test
Efficacy Test
Reason for submitting sleep test
Requesting sleep physician interpretation (includes complimentary bruxism report for patients with bruxism episodes index of 2.5/h or higher)
Question about sleep test (please include question in Comments)
Schedule Telemed Consultation with Sleep Doctor (Additional $100 charge. This is a new service and currently only Monday afternoon times are available for consultations. This availability may expand as the need arises. Upon requesting the consultation, we will reach out to your patient to schedule it.)
Patient Name
Patient Phone Number
Patient Email Address
Baseline Test:  
Efficacy Test:  
Requesting sleep physician interpretation:  
Question about sleep test:  
Post-treatment test for data analysis service:  
Doctor Name:  
Schedule Telemed Consultation with Sleep Doctor:  
Patient Name:  
Patient Phone Number:  
Patient Email Address:  
From  (email address)
Recipient  (email address)
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