Referrals from EmpowerSleep.com

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 NameLast Name
Referring doctor's office email*
example@example.com
Doctor phone Number*
Doctor fax number
Patient Details
Patient name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Patient email*
example@example.com
Patient mobile phone*
How does the patient prefer to be contacted?*

EmailPhoneText
Clinical Information
Virtual consultation requested For:*

Sleep ApneaInsomniaRestless legsOther
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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Empower Sleep is a digital sleep clinic, in your practice.

Referring Office Details

Patient Details

Clinical Information