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Online Referral Form
Select your test:
I AM A:
Healthcare Provider
Dentist
Patient (
Self-Referral
)
Downloadable PDF:
Healthcare Provider
Downloadable PDF:
Patient(Self-Referral)
Downloadable PDF:
Healthcare Dentist
Please complete the form below. We will contact you within 24hrs to complete registration for the home sleep apnea test.
I acknowledge the following:
I understand that the home sleep apnea test is not covered by OHIP and is a self-pay test.
I have explained to the patient that the home sleep apnea test is not covered by OHIP and is a private-pay test.
Please note:
We must be in contact with your patient to confirm shipping address & collect payment prior to mailing the device.
TEST TYPE:
Home Sleep Apnea Test only
Home Sleep Apnea Test & Consultation (if required)
PROVIDER INFORMATION:
Referring Provider Name
*
Referring Provider Number (Ex. CPSO, CNO)
*
OHIP Billing Number
How would you like to receive results?
*
Fax
Email
TEST TYPE:
Home Sleep Apnea Test
Has the clinic already collected payment?*
If the clinic has received payment, m-Health invoices the clinic monthly; otherwise, m-Health collects payment directly from the patient.
Yes
No
PROVIDER INFORMATION:
Referring Dentist Name
*
Referring Dentist Number (Ex. RCDSO)
*
How would you like to receive results?
*
Fax
Email
I would like to receive a confirmation email that this request was submitted successfully:
Yes
No
PATIENT INFORMATION:
First Name
*
Middle Name
Last Name
*
Gender
*
Select
M
F
Home Address
*
Address not found. Do you still want to use it?
Address
*
Unit
City
*
Province
*
ON
AB
BC
MB
NB
NL
NT
NS
NT
PE
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YT
Postal Code
*
DOB
*
Phone Number
*
Mobile
Home
Other
Email Address
*
Health Card Number
Version Code
CC Healthcare Provider:
Please include who you would like results sent to (ex. Family physician, dentist, specialist etc.)*
Full Name*
Provider Name*
Phone
*
Email Address or Fax
Provider Address
Address not found. Do you still want to use it?
Provider Address
Provider Unit
Provider City
Provider Province
Please select...
ON
AB
BC
MB
NB
NL
NT
NS
NT
PE
QC
SK
YT
Provider Postal Code
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REASON FOR REFERRAL*
Snoring
Central Sleep Apnea R/O
Teeth grinding/ clenching
Pauses or choking while asleep
Restless sleep
Obstructive Sleep Apnea R/O
Pauses or choking while asleep
Daytime fatigue
Obesity
Restless leg/ limb syndrome
Insomnia
Other
ADDITIONAL NOTES:
Submit