Home Sleep Test Reading Request
Remember to share the patient's sleep test with care@empowersleep.com
Referring Doctor Information
Dental office name
*
Dental office phone number
*
Please enter a valid phone number.
Dental office email
*
example@example.com
Patient Information
Patient name
*
First Name
Last Name
Patient date of birth
*
-
Month
-
Day
Year
Date of birth
Date of home sleep test to be interpreted
*
-
Month
-
Day
Year
Type of Home Sleep Test
*
SleepImage
WatchPAT
Other
Patient Vivos Score ID number
*
Type of home sleep test
*
Sleep Image
WatchPAT
Other
What's is the indication for a sleep test (epworth, STOPBANG, etc.)? This will be helpful to ensure a personalized report
*
Upload additional clinical information. No need to upload HST report if it's been shared through SleepImage/Cloudpat.
Upload clinical information
Drag and drop files here
Choose a file
Cancel
of
HST
*
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Home Sleep Test Interpretation (Report only)
HSTs will be interpreted within 24-48 business hours. Please don't forget to share the request in SleepImage or CloudPAT with care@empowersleep.com
$
75.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit request
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