Empower Sleep is a digital sleep clinic, in your practice.
After submitting this form, we will reach out to the patient, verify insurance, get them scheduled, and collaborate with you to improve their sleep and health. If a home sleep test has not been completed, we can ship one to the patient.
Referring Office Details
Referring doctor's name
*
First Name
Last Name
Referring doctor's office email
*
example@example.com
Doctor phone Number
*
Doctor fax number
Patient Details
Patient name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Patient email
*
example@example.com
Patient mobile phone
*
How does the patient prefer to be contacted?
*
Email
Phone
Text
Clinical Information
Virtual consultation requested For:
*
Sleep Apnea
Insomnia
Restless legs
Other
Upload patient's medical insurance info (front/back of card, Verification of Benefits [VOB], etc.). We will run an eligibility check and reach out to the patient.
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Reason for referral or findings?
*
Additional documents (e.g. doctors' notes, prior sleep test, etc.)
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Number
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