Empower Sleep is a digital sleep clinic, in your practice.
After submitting this form, we will reach out to the patient, verify insurance, get them scheduled, and collaborate with you to improve their sleep and health. If a home sleep test has not been completed, we can ship one to the patient.
Referring Office Details
Referring doctor's name
*
First Name
Last Name
Referring doctor's office email
*
example@example.com
Doctor phone Number
*
Format: 1 (000) 000-0000.
Doctor fax number
Format: 1 (000) 000-0000.
Patient Details
Patient name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Patient email
*
example@example.com
Patient mobile phone
*
Format: (000) 000-0000.
How does the patient prefer to be contacted?
*
Email
Phone
Text
Patient home state
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Unknown
Gender assigned at birth
Female
Male
Clinical Information
Virtual consultation requested For:
*
Sleep Apnea
Insomnia
Restless legs
Other
Upload patient's medical insurance info (front/back of card, Verification of Benefits [VOB], etc.). We will run an eligibility check and reach out to the patient.
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Reason for referral or findings?
*
Additional documents (e.g. doctors' notes, prior sleep test, etc.)
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Number
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