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Our family of clinics to support you include:

Patient Symptoms

  • Patient information

  • DD slash MM slash YYYY
  • DD slash MM slash YYYY
  • The policy or plan number and member ID or ID number for your secondary coverage.
  • Health information

  • Please carefully read and check the boxes that are applicable. This is an important part of your screening.
  • Epworth Sleepiness Scale

  • This refers to normal daytime activity over the past several weeks or months.
    No chance of dozingSlight chance of dozingModerate chance of dozingHigh chance of dozing
    Sitting & reading
    Watching TV
    Sitting inactive in a public place
    As a passenger in a car for an hour
    Laying down in the afternoon
    Sitting & talking to someone
    Sitting quietly after lunch (no alcohol)
    In a car & stopped for a few minutes
  • Release of Information

  • I authorize CanSleep Services to send an estimate, sleep study results and any other medical documentation required for pre-approval purposes. I understand that this is for information purposes and there is nothing being claimed with my insurance provider at this time. By supplying my home/cell phone number, email address and any other personal information, I authorize CanSleep Services to use my personal information to contact me regarding appointment times, referral notices, result information, appointment reminders, and other limited information. I am also aware it is my responsibility to keep my contact information current.
  • This field is for validation purposes and should be left unchanged.