Refer A Patient

Refer A Patient to Dental Sleep Care

We make it easy to refer your patients for oral appliance therapy. Complete the secure referral form below and our team will coordinate with your office and the patient to provide attentive comprehensive care.

How to Refer A Patient

Please complete the provider information below. Once received our team will contact your office to coordinate referral and arrange for secure exchange of patient information. Please do not submit patient information or protected health information through this form.

Patient Referral Coordination Request Form

Referral coordination request for healthcare providers referring patients to Dental Sleep Care for oral appliance therapy.

Please do not submit patient information or other PHI through this form. This form is for healthcare providers to request referral coordination only.

Referring Provider Name

First Last

Practice Name(Required)

Provider Phone(Required)

Provider Email

Message to Dental Sleep Care (optional)

Please do not include Patient’s identity or health information in this form. We will contact you to coordinate the referral