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First Name (patient)

Last Name (patient)

Health Card number

Date of Birth (patient)

Contact Phone Number (patient)

Email Address (Patient)

Request forREASON FOR REFERRAL
(Select A Minimum Of TWO Symptoms)

Snoring

Insomnia

Suspected OSA

Restless Legs

Excessive Daytime SleepinessNarcolepsyAbnormal Sleep Behavior

Has this patient had a previous sleep study performed anywhere in Ontario? (Check one)

Yes

NoIf YES, please specify date & location last sleep study:REFERRING PHYSICIANPlease enter your full name. By entering your Full Name here you attest that you, the referring physician are signing this referral in an electronic submission.Full Name

Phone Number (Physician)

Fax Number (Physician)

OHIP Billing Number

Is the patient currently on Oxygen?

Yes

Does the patient have any Allergies?
‍(Check one)

Yes

Does the patient have Special Needs?
‍(Check All That Apply)

Language Barrier

Requires an Attendant

Ambulation Restricted / Wheelchair

Additional Comments & RequirementsAttach Additional DocumentsIf any documents (eg: patient profile, medication history) accompany this referral, please press the “Attach Additional Documents” button to send accompanying documents via e-mail.

‍Return to this page once completed to click the blue “Submit” form and you will receive a green message stating your referral has been received.

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Your submission has been received!

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Online Referral Form
(For Referring MD’s ONLY)

HERE

‍(Location Specific Fax Numbers can be found on “Locations” Page)

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