Center for Sleep and Wake Disorders
 
 Patient Registration Form  
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 information.

Denotes required field. *

Please select the service your doctor referred you for:*




Please write a brief description of why you were referred to the Center for
Sleep and Wake Disorders:
*

Please enter the following information about yourself:
 

Last Name *
First Name *
DOB *
Sex*

Marital Status
Employer
Drug Allergies * **Please list any drug allergies you may have. If none, please specify "none."
 
Address *
City *
State *
Zip *
Height in Feet *
Height in Inches *
Weight *
Home Phone * Numbers only, including area code: e.g. 3016541575
Work Phone Numbers only, including area code: e.g. 3016541575
Cell Phone Numbers only, including area code: e.g. 3016541575
What is your preferred contact number?
Email Address *
 
Please Tell Us About Your Other Physicians To Help Us Optimize Your Care

Referring Doctor
First Name *

Last Name*
Phone * Numbers only, including area code: e.g. 3016541575
Address *
City *
State *
ZIP *
Other Treating Drs: 
Other Treating Drs:
 

The current standard of care is that all eligible prescriptions be electronically sent to your pharmacy.

This process is secure, has been demonstrated to significantly increase patient safety, and reduces the time that it takes for patients to fill their medications. Please fill in the following information about your preferred pharmacy (you may always change this information later):

Pharmacy name:
Address (or street, if full address is unavailable):
City/ZIP code:
 

Is the patient under 18?
 
If the patient is younger than 18 years old check here:
 

Primary Insurance
Do you have insurance?
I have
 
 

Do you have secondary insurance?
 
Secondary Insurance
 
 

Please fill in your referral information.
 
Referral Number
 
don't need a


These questions are required by Federal law for statistical research purposes, and you may decline to answer:
What is your race? (you may check more than one box) American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Other race
I decline to give this information

What is your ethnicity? Hispanic or Latino
Not Hispanic or Latino
Unknown
I decline to give this information
 


That's it You're all done. Please click on the Submit button.

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