Login
Appointment

Refer A Patient

Sleep Clinic Referral Form
PATIENT INFORMATION

Please provide the patient's basic information for the sleep consultation referral.

Patient first name is required.
Patient last name is required.
The email address must be valid.
Mobile number must be 10 digits.
REFERRER INFORMATION

Please provide your information as the referring healthcare professional.

Referrer name is required.
Referrer license is required.
DIAGNOSIS

Unless otherwise indicated, Dorma will handle treatment after the test. Our protocol allows for a quick test followed by a consultation with a sleep medicine specialist, who may recommend treatment.

TREATMENT (Optional)
Continuous Positive Airway Pressure (CPAP):
cmH2O
- cmH2O
CONSENT & FOLLOW-UP
Patient consent is required.

Download Our Requisition


Download The English PDF Requisition


Download The French PDF Requisition

Working With Medesync EMR?

Click To Add The Requisition To Your Medesync (English)

Click To Add The Requisition To Your Medesync (French)

Prefer to get your patient’s result another way?

Let us know what format works best; hard copy, fax, or other and we will send results in the format that works for you.

Please e-mail [email protected] with any requests and we will do our best to accomodate them

Appointment
1 855 218 5186