Sleep Referrals - mHealth Online Referrals

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

PATIENT INFORMATION

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

Provider Postal Code

REASON FOR REFERRAL*

PRE-EXISTING CONDITION(S)

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.

Online Referral Form

Select your test:

I AM A:

I acknowledge the following:

PATIENT INFORMATION

REASON FOR REFERRAL*

PRE-EXISTING CONDITION(S)