New Pediatric Referral Form: Ages 11-17

Please correct the errors described below.

Accredited by the American Academy of Sleep Medicine

PLEASE INCLUDE CHART NOTES, MEDICATION LIST AND FRONT/BACK OF RECENT INSURANCE CARDS

Patient Name:

Date of Birth:

Phone:

Parent/Guardian Name

Parent/Guardian DOB

Home/Work Phone

Cell Phone

Primary Insurance

Primary Insurance ID

Secondary Insurance

Secondary Insurance ID

MEDICAL HISTORY (a history and physical exam is required)

Suspected Diagnosis:

Signs/Symptoms:

Sleep apnea Restless leg syndrome Insomnia Narcolepsy

Snoring Witnessed apnea Obesity Daytime sleepiness Hyperactivity Behavioral issues

Suspected Diagnosis:

Special Needs:

CAD HTN Stroke COPD Tonsillar enlargement Tonsillectomy +/- Adenoidectomy ADD/ADHD

Nocturnal O2: L/min Wheelchair Medical Interpreter

Patient is being referred for (check only ONE):

Consultation and Management. Visit with a sleep specialist to evaluate and treat patient.

Or, a Direct Sleep Study (Listed below) – In which the Ordering provider is responsible for discussing test results with patient and initiating treatment, if indicated.

Diagnostic Polysomnogram: Full night sleep study

ORDERING CLINICIAN INFORMATION

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name

Signature

Address

Phone

Fax

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Accredited by the American Academy of Sleep Medicine

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