1. No category

Date:
Patient Information
First Name:
Last Name:
DOB:
Work Ph:
Home Ph:
Sound sleep. Sound health.
Cell Ph:
Email Address:
referral form
Physician Information
Referring Practice:
Fax this form to 919.462.8082
along with a copy of
Fax:
Ph:
• Patient Demographics
Referring Doctor:
• Medical History/Medications
Dr. Signature:
• Insurance Card
We will verify insurance eligibility and
Diagnosis / Symptoms (Please check all that apply.)
contact and schedule the patient.
O Difficulty falling/staying asleep
0 Wake up gasping
0 Witnessed pause in breathing
0 Snoring
0 Previously diagnosed sleep apnea
Other
C) Daytime sleepiness
O
Frequent awakening
CARY CENTER
130 Preston Executive Drive
Cary, NC 27513
(Please check one.)
SLEEP SERVICES
p 919.462.8081
Our sleep physician will manage patient's care for their sleep health.
f 919.462.8082
0 Evaluate & Treat
parkwaysleep.com
(includes the following)
• Pre-consult with our sleep physician
• Recommended testing based on consult appointment
• Post-consult to go over results and treatment options
• CPAP setup if recommended
• Ongoing management of care
O Comprehensive Sleep Service
(includes the following)
• Split- Night Sleep Study (Must meet A1 -11>30 during first 2 hours to qualify for Split - Night Study.)
• Post-consult to go over testing results and treatment options
• CPAP setup if recommended
• Ongoing management of care
SLEEP STUDIES
NO sleep physician involvement; referring physician will manage patient's care for sleep health.
0
O Split-Night Sleep Study w/CPAP Setup
PAP-NAPs
(if indicated)
Must meet AHI>30 during the first 2 hours to meet
PAP-NAPs are indicated for patients who are
split-night criteria.
Patients will benefit from techniques to reduce anxiety
and frustration and increase PAP adherence through a
non-compliant, failing or just unable to tolerate CPAP.
0 Diagnostic Sleep Study
short daytime encounter.
O CPAP Titration Sleep Study w/CPAP Setup
0
O Home Study (Apnea Link)
Co Multiple Sleep Latency Test (includes Diagnostic Study)
Actigraphy
Neurofeedback
0 Maintenance of Wakefulness Test
CPAP & OTHER MEDICAL EQUIPMENT
Referring physician will be responsible to follow patient's care.
O CPAP Setup
Pressure
0 CPAP Mask & Supplies
0 Auto-Pap
cmH2O
O Provent®
Max Pressure
cmH2O
Small, self-adhering, disposable nasal devices
Min Pressure
cmH2O
that are clinically proven to help with OSA.