Feeling Great Sleep Center

Patient Information

Patient Name

Date Of Birth Gender

Address

City

State

Zip

Phone

Other Phone

Insurance Information

Primary Insurance Self Pay?

Policy #

Secondary Insurance

Policy #

Physician Order

Diagnostic Sleep Study and PAP Titration if positive for Sleep Apnea

Sleep Specialist Physician Consultation

See before Sleep Study See after Sleep Study

PAP Titration Sleep Study – evaluation for patients already on PAP therapy (unless new machine needed)

PSG & MWT – (Maintenance of Wakefulness Test – used to determine daytime alertness)

PSG & MSLT – (Multiple Sleep Latency Test – used to rule out narcolepsy)

Diagnoses and Medical Screening Information

Primary Diagnosis

Patient's Sleep History

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Other Information

(MAY TYPE OR PASTE MEDICAL NOTES)

Physician Information

Physician's Name Practice

Address

City

State

Zip

Phone

Fax

Referral Sent by

Patient's Preferred Location

Contact Details

Durham: 919-477-1588
Toll Free: 866-499-1588
E-Mail: support@FeelingGreatSleepCenter.com

Fax Durham: 919-477-1688
Fax Toll Free: 866-499-1288

Sleep Medical Center Locations: Durham, Burlington, Jacksonville, North Carolina
Feeling Great Respiratory Equipment: Oxygen, CPAP / BiPAP, Nebulizers

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