Provider Inquiry List

1

What is your name?* This field is required.

First Name

Last Name

2

What is the name of your practice/group?* This field is required.

3

What is your email?* This field is required.

example@example.com

4

What is your phone number?

Please enter a valid phone number.

5

Which of the following best describe your practice/group?

Physician group/office

Dental group/office

Hospital

Health Coach

Employer providing benefits to employees

Other

6

Where is your office located?

7

Do you currently make sleep apnea appliances or offer treatment in your office?

YESNO

8

If so, how many appliances do you make per month?

10

How many sleep tests do you do per month?

11

How many appliances would you like to make per month?

12

What limits your ability (if any) to provide sleep-related services?Check all that apply

We lack sleep or ENT physician collaboration

We don't have a sleep specialist to interpret sleep studies

I live in a state where I can not dispense sleep studies

I don't have a sleep physician to refer to for consultations

I don't receive enough referrals

I don't feel comfortable doing sleep medicine in my office

We have a good system in place

Other

14

If not mentioned above, how can we best support you?

15

Would you like to have a virtual sleep specialist to help co-manage patients, read sleep studies, dispense prescriptions (appliance and/or CPAP), and do virtual consultations for patients?

YESNO

16

Once we are licensed in your state would you like for us to reach out to you?

YESNO