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Refer a Patient
Provider LOGIN
Online Referral Form
Select your test:
I AM A:
Healthcare Provider
Dentist
Patient (
Self-Referral
)
Optional Download PDF Form:
Healthcare Provider/Dentist
Patient(Self-Referral)
I acknowledge the following:
I understand this test is not covered by OHIP and that I am required to pay $249.00 for the test and service (includes shipping & handling)
I have explained to the patient that the home sleep test is not covered by OHIP and that the patient is required to pay $249.00 (includes shipping & handling)
Home Sleep Test Overview:
Once your information and shipping address is confirmed, the device will be shipped to your home
The test duration is for 2-nights
The device will be picked up from your home by FedEx
The data will be interpreted by a sleep physician
The sleep physician will provide you a follow up consultation
Once patient information and shipping address is confirmed, the device will be shipped to the patient’s home
The test duration is for 2-nights
The device will be picked up from the patient’s home by FedEx
The data will be interpreted by a sleep physician
The sleep physician will provide your patient a follow up consultation
Please select one of the following:
*
Home sleep test and consult with sleep specialist
Home sleep test only
Name of Referring Provider
*
CPSO/CNO Number
*
How would you like to receive results?
*
Fax
Secure Email
Name of Referring Dentist
*
RCDSO Number
*
How would you like to receive results?
*
Fax
Secure Email
Dentist Address
*
Dentist Unit
Dentist City
*
Dentist Province
*
Please select...
ON
AB
BC
MB
NB
NL
NT
NS
NT
PE
QC
SK
YT
Dentist Postal Code
*
Patient Email
*
Verify Patient Email
*
I wish to receive a confirmation email that the referral was submitted successfully
I wish to have the results securely emailed to the email address entered above.
PATIENT INFORMATION
First Name
*
Middle Name
Last Name
*
Gender
*
Select
M
F
Address
*
Unit
City
*
Province
*
ON
AB
BC
MB
NB
NL
NT
NS
NT
PE
QC
SK
YT
Postal Code
*
DOB
*
Phone
*
Health Card Number
*
Version Code
*
Patient Email
*
CC Healthcare Provider Full Name*
Healthcare Provider (ex. Family physician, dentist, Nurse Practitioner, etc) you would like Results sent to*
Provider Fax
*
Provider Phone
*
Provider Address
Provider Unit
Provider City
Provider Province
Please select...
ON
AB
BC
MB
NB
NL
NT
NS
NT
PE
QC
SK
YT
Provider Postal Code
+ Add HealthCare Provider
REASON FOR REFERRAL*
Snoring
Central Sleep Apnea R/O
Teeth grinding/ clenching
Pauses or choking while asleep
Restless sleep
Obstructive Sleep Apnea R/O
Pauses or choking while asleep
Daytime fatigue
Obesity
Restless leg/ limb syndrome
Insomnia
Other
PRE-EXISTING CONDITION(S)
Chronic Pain
Depression
Pacemaker/ ICD
COPD
Gastric Acid Reflux
High Blood Pressure
Heart Disease
Heart Failure
Fibromyalgia
Weight Gain
Atrial Fibrillation
Diabetes
Stroke
Other Medical Hx/ Medications
Notes
If you wish to receive a confirmation email that the referral was submitted successfully, please enter the email you want the confirmation to be sent to:
I wish to have the results securely emailed to the email address entered above.
Submit