Fax this Referral to:

212-342-4784

PLEASE INCLUDE A COPY OF YOUR LAST CLINIC NOTE

Patient Demographics:

Date of referral

 

 

 

 

Name:

 

 

 

 

Insurance:

 

 

Male:

 

Address:

 

 

 

 

Date of Birth:

 

 

Female:

 

Home Phone:

(†††††††††††† )

 

 

 

cell/work tel

(†††††††††††† )

 

please confirm these numbers are accurate with your pt

Clinical Information

History/Reason for Referral:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Height

 

Weight

 

 

 

 

Are there any oxygen requirements?If so, how much?

 

 

Does the pt have a cardiac arrthymia? Please provide more info if yes

________________________________________________________________

Services Requested (Check all that apply):

Referrals from primary care will usually receive a consultation in addition to indicated sleep testing. However if your

pt should proceed directly to sleep testing, AND you will be providing post testing disease management,

then check the boxes below:

Sleep Study Only:

 

with MWT:

 

with MSLT:

 

other:____________________

Symptoms (Check all that apply):

Morning Headaches:

 

Frequent Arousals:

 

Snoring:

 

Daytime Somnolence:

 

Awakening with Dry Mouth:

 

Insomnia:

 

Depression:

 

Witnessed Apneas:

 

Nocturia:

 

Nocturnal Abnl Behavior:

 

Difficulty Concentrating/Focusing:

 

Other:

 

(Explain):

 

 

 

 

 

 

 

 

 

 

 

 

 

Suspected Diagnosis (Check all that apply):

Obstructive Sleep Apnea:

 

Sleep Related Hypoventilation/Hypoxemia:

 

Narcolepsy:

 

Central Sleep Apnea:

 

Circadian Rhythm Disorder:

 

Parasomnia:

 

Restless Leg Syndrome:

 

Insomnia:

 

(Due to):

 

 

 

 

 

 

Other:

 

(Explain):

 

 

 

 

 

 

Ordering MD Information

Referring PCP

 

 

 

 

Email

 

 

 

 

Address:

 AIM Clinic

 

 

 

 

Phone Number:

( 305 6354)

 

Pager

 

 

 

 

Fax Number:

( 305 6279 )

 

 

Referring MD Signature:

 

 

 

 

 

 

 

**Signature is required for this request to be accepted.

Drop off completed form in VC205 Sleep Study referral box for AIM staff to fax for you.

Pt should be given Sleepís # 212 305 -7591 to call and f/u on scheduling info. F 212-342-4784

Please call Sleep Center directly if you are requesting an expedited evaluation.