Please complete the form below to request a consult and/or appointment:
* = Required field
If you have the patients last visit notes, please fax to 407-898-9443 or toll free at 877-898-9443.
Email Address or Name (Medical Office or Sender):*
Patient Name:*
Date of Birth:*
Gestational Age:
Parent/Guardian Name:*
Parent/Guardian Phone:*
Referring Physician:*
Referring Physician Phone Number:*
Referring Physician Fax Number:
Do you want to be contacted with the appointment date when scheduled with the patient?
Yes
No
Referring Office
Select the time range that is best for patient/parent:
8:30am - 10:00am
10:00am - 11:30am
1:00pm - 2:30pm
2:30pm - 4:00pm
Please select indication for consultation and/or sleep lab referral:
Obstructive sleep apnea syndrome (327.23)
Central sleep apnea syndrome (327.21)
Attention deficit hyperactivity disorder (314.01) or attention deficit disorder (314.00) with suspected obstructive sleep apnea syndrome
Narcolepsy (347)
Hypersomnia (327.10)
Sleep parasomnias (307.46) (Sleep terrors, confusional arousals, sleep walking)
Insomnia (327.00)
Circadian rhythm disorder (327.30) (Delayed/Advanced sleep phase syndrome)
Other Diagnosis
Please select the type of service requested:
Sleep clinic consultation and diagnostic sleep polysomnography - Diagnostic sleep study (95810)
Sleep clinic consultation (99499 or 99244 or 99245)
Diagnostic sleep polysomnography with CPAP titration (95811)
Multiple sleep latency test (95805)
Would you like Sleep Lab to refer patients for further treatment (if needed)?:
Yes
No
Comments/Other Diagnosis:
OPPSA Home Page
Sleep Disorders Clinic
Pulmonary Care Services
Sleep Lab & Pulmonary
Diagnostic Services
Home
Locations and Directions
Click here for the paperwork you will need to print, complete and return for your childs appointment
Contact Us
