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TSI - Patient Referral Form

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9 views

TSI - Patient Referral Form

Uploaded by

greenhatlab26
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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The Sleep Institute - Comprehensive Sleep Clinic

Red Deer - Calgary - Edmonton


Unit 160, 2206 2 St SW, Calgary, AB T2S 3C5
Tel: 403-879-8263
Fax: 403-879-8261
Email: [email protected]

PATIENT REFERRAL FORM


Once the referral form is submitted, patients will be contacted directly for appointments.

Surname: Given Name(s): Sex: M F

Address:
City Province Postal Code
Date of Birth: / / Personal Health Care #:
Month Day Year
Home Phone: Work Phone: Cell Phone:

Email Address: Occupation:

Referred By: MD Pracid:

Address:
City Province Postal Code

Phone: Fax: Family Physician:


(if different from Referring Physician)

Mandatory - Check all that apply:


( ) BMI >= 35
( ) BMI >= 30, plus comorbidity (HTN, CVD, Pulm Disease)
( ) Pt/Clinician identified sleep issue

Current Medications / Additional Medical Information: For Office Use Only

The Sleep Institute is a comprehensive sleep clinic that provides expert sleep care led by Certified Sleep Specialist Physicians. Consultations are covered by
Alberta and NWT Health.
We offer alternative therapies such as oral appliance therapy and weight management programs for obstructive sleep apnea, along with Level 3 testing, CBTI, consultations
with sleep psychologists, and care from behavioral sleep medicine specialists. We address a range of sleep disorders from OSA to insomnia.

Copies of these referral forms can also be downloaded from our website at
March 2024 www.thesleepinstitute.ca (under “Referrals”) and returned by fax or email.

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