* Denotes Required Fields


Has patient had a previous sleep study? *
Patient has had a sleep study within the past year.
Patient has had a sleep study within the past five years.
Patient has had a sleep study over five years ago.
Patient has been on CPAP in the past, not currently on CPAP.
Patient is currently on CPAP
Patient is currently on BIPAP

Patients who have had previous studies will be booked an assessment with a sleep specialist prior to overnight study as per OHIP regulations. All previous reports should be attached if available.
(Files must be less than 4 MB. Allowed file types: pdf doc docx rtf)

Referring physician*

Other physicians
Please list the names and specialties of any other physicians involved in the patient’s care:
Doctor's Name Doctor's Specialty

Important: Please fill in each section of this requisition in order for us to adequately triage the referral.

Patients should be able to care for themselves in the lab. Please provide us with the following information:
Infectious Diseases

Symptoms leading to referral
at night only

Working diagnosis

Additional medical information

ADDITIONAL INFORMATION: Thank you for the referral. Your office will be notified of the sleep study appointment or consultation by fax or email and we will contact the patient directly for further information.

For clinic information have your patient visit our website at www.sleep-clinic.ca.
When you click the submit button, you will be shown a pdf copy of your completed referral. Please print or download and save a copy of this for your records

Page 1/4