Trusted Sleep Medicine Consultants since 2011
Online Clinic
$50 per visit
Phone or video visit
Licensed Physicians
Any Sleep Problems (Snoring, Fatigue & Day Time Sleepiness etc.)
Doctor's note
Labs
Patient Form
Patient Form
Patient General and Medical History Form
PATIENT NAME
*
Gender
*
DATE OF BIRTH
*
mm/dd/yyyy
AGE
*
EMAIL & PHONE & HOME ADDRESS
*
INSURANCE NAME, GROUP ID, MEMBER ID & EMPLOYER NAME:
*
DATE APPOINTMENT
*
mm/dd/yyyy
TIME OF APPOINTMENT
*
PLEASE DESCRIBE WHY YOU WANT TO SEE THE DOCTOR
*
CURRENT MEDICAL PROBLEMS
*
LIST ANY SURGERIES OR HOSPITALIZATIONS IN YOUR LIFE TIME
*
HOME MEDICATIONS and the prescribing doctors name
*
Name & number of pharmacy or DME company
*
Discontinued/Completed Medications & Treatments
*
ALLERGIES
*
Social and Functional History
*
DOES YOUR PARENTS/GRAND PARENTS/SIBLINGS HAVE ANY MEDICAL CONDITIONS
*
DO YOU HAVE ANY ADDITIONAL SYMPTOMS
*
If required I/we give consent to consult with doctor through audio-video conference. For this service your insurance will be billed for payment if your insurance allows: I/we give consent to obtain medical records from other healthcare providers to help in coordination of care.
*
Electronic Signature of patient or Authorized representative
*
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