ORAL APPLIANCE THERAPY
SNORING & SLEEP APNEA
ABOUT US
NEW PATIENT INTAKE FORM
ALTERNATE LOCATION
Contact/Request Appointment
REFERRALS
250-479-8100
ORAL APPLIANCE THERAPY
SNORING & SLEEP APNEA
ABOUT US
NEW PATIENT INTAKE FORM
ALTERNATE LOCATION
Contact/Request Appointment
REFERRALS
250-479-8100
Referral Form
Introducing:
*
First Name
Last Name
Email
Date of birth
MM
DD
YYYY
Phone number
(###)
###
####
Address
City
Province
Postal Code
Preferred method of contact
Email
Phone
Gender
Male
Female
REFERRING DOCTOR
Doctor's name
Clinic name
Clinic Phone number
(###)
###
####
Fax
(###)
###
####
Clinic Address
City
Province
Postal Code
REASONS FOR THIS CONSULT
Please choose all that apply:
Snoring
Obstructive Sleep Apnea
Breathing pauses or choking episodes at night
Oral Appliance Therapy
Treatment follow-up
CPAP non-compliance
MATRx testing
Level III Sleep Screening
Anything else you would like to tell us?
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