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1
How can we help you today?
I am interested in improving my sleep
I am a healthcare provider and I want to implement Empower Sleep in my practice
Other
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2
UniqueID
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3
What is your name?
First Name
Last Name
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4
What is your email address?
example@example.com
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5
Which of the following best describes your main wellness or health goal?
This will help us to tailor the treatment plan for your needs
I want to improve my quality of sleep
I want to improve my quality of life
I want to live a longer & healthier life
I want to improve my mental health
I am managing a chronic health condition (cardiac health, hormonal health, diabetes, etc.)
I want to increase physical or mental performance
I want to disturb my bed partner less
Other
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6
Have you been previously diagnosed with a sleep condition?
This will help us to tailor the treatment plan for your needs
Not Diagnosed
Sleep Apnea
Insomnia
Restless Legs Syndrome
Other
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7
Which of the following best describes the objective for you first visit?
This will help us to tailor the treatment plan for your needs
I am would like to learn how to improve my sleep
I am looking to consult an Empower Sleep sleep physician
I am looking for a comprehensive treatment
I am looking for an at home sleep test
I am looking for help with a specific sleep aid (CPAP, dental appliance, medication, etc)
Other
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8
Which state do you currently live in?
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Washington D.C.
Delaware
Florida
Georgia
Hawaii
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Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
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Other
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Rhode Island
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Tennessee
Texas
Utah
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Washington
West Virginia
Wisconsin
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Washington D.C.
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
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New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Other
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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9
How can we help guide you towards better sleep?
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This field is required.
This will help us build a comprehensive plan to get your sleep back on track
I am looking for educational materials to improve my sleep
I need continuous sleep guidance from a board-certified sleep physician
I would like to treat my insomnia
I would like to eliminate snoring and/or prevent sleep apnea
I would like an FDA-approved sleep test to understand my sleep quality
Other
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10
How did you find out about Empower Sleep?
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Google search
Instagram
Facebook
Doctor
Dentist
Friend/colleague
LinkedIn
Podcast
Insurance Website
Other
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11
Who is the doctor/dentist that referred you?
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12
Check below to agree to our
Privacy Policy
,
Terms & Conditions
, and
Telemedicine Consent
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I agree
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13
What is your phone number?
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14
How would you like to schedule your first visit?
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I would like to schedule a telemedicine visit now for $199
I would like to use my insurance and schedule a visit when my benefits are verified
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15
How would you like to pay? Calculated
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16
What is your date of birth?
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Please enter in the format MM/DD/YYYY
Enter in the format MM/DD/YYYY
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17
What is your date-of-birth?
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Tap below and select or enter in the format: mm/dd/yyyy
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18
What is your address associated with your insurance? This will help us verify your benefits swiftly..
All information will remain confidential
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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United States
Afghanistan
Albania
Algeria
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Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
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The Bahamas
Bahrain
Bangladesh
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Belgium
Belize
Benin
Bermuda
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Bolivia
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Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
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Canada
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Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
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Cook Islands
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Croatia
Cuba
Curaçao
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Djibouti
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El Salvador
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Ethiopia
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Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
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Guinea
Guinea-Bissau
Guyana
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Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
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Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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19
Upload a picture of your insurance card (front).
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We will run your benefits and get back to you
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20
Upload a picture of your insurance card (back).
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We will run your benefits and get back to you
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21
When we verify your insurance, we will reach out to schedule your visit. How would you like for us to communicate with you?
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Schedule time with a clinical coordinator now
Have a coordinator call me whenever my benefits are verified
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22
Let's start with step 1: Schedule time with a clinical coordinator to learn more
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We're excited to meet you!
Schedule time with a clinical coordinator to learn more!
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