Referral Request

Referral Request*

Patient*

First Name *

Last Name *

Healthcard *

Day of birth*

Email

Main Phone*

Cell Phone

Street Address *

City *

Country *

Province/State *

Postal/ZIP Code *

Has patient had a previous sleep study? *

Patient has had a sleep study within the past year.

Where was the sleep study done?

When was the sleep study done?*

Patient has had a sleep study within the past five years.

Where was the sleep study done?

When was the sleep study done?*

Patient has had a sleep study over five years ago.

Where was the sleep study done?

When was the sleep study done?*

Patient has been on CPAP in the past, not currently on CPAP.

Patient is currently on CPAP

Current Pressure*

Patient is currently on BIPAP

IPAP (cm H2O)*

EPAP (cm H2O)*

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*

First Name *

Last Name *

Billing Number *

Email

Phone*

Fax*

Street Address

City *

Country

Province/State

Postal/ZIP Code

Family Doctor (if different to referring doctor)

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:

Problems with mobility

Communication (hearing impaired, language, etc)

Developmental / Psychological Disorder

Urinary incontinence

Fecal incontinence

History of Violence

History of Seizure Disorder

Infectious Diseases

TB MRSA VRE Other

Symptoms leading to referral

Snoring Snoring with apnea

Unrefreshing sleep Frequent awakenings

Excessive daytime sleepiness Difficulty initiating or maintaining sleep

Restless legs Unusual movement during sleep

Abnormal behaviour during sleep Patient is on oxygen

Litres per minute:*

at night only

Significantly overweight (BMI >30) Other

Preferred Unit of Measurement*

What is patient's current weight in kilograms?*

What is patient's height in centimeters?*

What is patient's current weight in pounds?*

What is patient's height in feet and inches?*

Working diagnosis

Sleep apnea Insomnia Narcolepsy

Restless Legs Syndrome Other

Additional medical information

Cardiac History Hypertension DM

COPD Other

Medically Stable*

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