VivoScore Interpretation request

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 NameLast Name
Patient Home State*
Patient date of birth*

MonthDayYear
Date of birth
Date of home sleep test to be interpreted (date, when the patient woke up)*

MonthDayYear
Patient email: To make it easy for you, we're happy to send the patient their report directly and cc your office. You can also skip this.
example@example.com
Type of Home Sleep Test*

SleepImageWatchPATOther
Patient Vivos Score ID number*
Type of home sleep test*

Sleep ImageWatchPATOther
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.

Cancelof
📣 Announcement: We've launched educational & personalized home sleep test reports! View a sample report here.
Do you want an educational & personalized HST report to share with your patient? There is no additional cost!

YesNo

HST*

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

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Home Sleep Test Reading Request

Referring Doctor Information

Patient Information