Refer A Patient

If you prefer, you may call the office directly at 817-332-7433,
or use our printable form and fax to 817-394-6282.

If you have any questions, please call the office or send email to referrals@sleepconsultants.com.
If you are an individual and would like to self-refer (without a doctor’s
recommendation) please use the self-referral form
here.

Referring physicians may also send referrals to us via Direct Messaging.

PATIENT REFERRAL Date:  

Prior sleep testing?  Yes No   If yes, when and where:

Sleep-related diagnosis(es):

Patient Information:
Last Name:    First Name/Middle Initial:
Address:      City/State/Zip:
Home Phone:     Cell Phone:
SS#: DOB (mm/dd/yyyy):
Sex: M F     Marital Status: M S D W
Employer:   Phone:
Referring Doctor:    NPI:
Address:     City/State/Zip:
Phone:     Fax:
Specialty:    Office Contact:
Primary Care Physician:    NPI:
Phone:     PCP Fax:


Primary Insurance:
Insurance Company:
ID No.   Group No.
Name of Insured:   Relationship:
Insured’s Birth Date (mm/dd/yyyy): SSN
Sex: Male Female
Address:
Phone:

Secondary Insurance:
Insurance Company:
ID No.   Group No.
Name of Insured:   Relationship:
Insured’s Birth Date (mm/dd/yyyy):   SSN
Sex: Male Female
Address:
Phone:


“Please evaluate and/or perform studies on the above patient.”

                      
Typed Name of Ordering Physician                                          Date

Any other information you need to relay to us?

Name of person completing this form
Email (optional)

Please send records of the most recent physical examination and pertinent medical assessment. Please also send any sleep-related medical records (prior sleep studies, etc.)