Apnea del Sueño Negativo

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Summary: Mild — Your answers suggest that there is a low probability of having obstructive sleep apnea (OSA) or sleep disordered breathing. This is a simple questionnaire that cannot and does not substitute for physician directed medical care and does not mean that sleep disorders have been ruled out in your case. For a more thorough evaluation, please see your primary care physician or make an appointment with our office.

[—- PATIENT:print this referral form, complete the top section, and give to your physician.—- ]

Orlando Sleep Medicine Center
Navin Verma, MD Board Certified in Sleep Medicine
849 Oakwater Circle, Orlando FL, 32806
phone: (407) 704- 8537

Patient Name:___________________________________ Patient Date of Birth:_____________________

Parent/Guardian (if under 18):__________________________________ Relationship:____________________

Home Phone:______________________________ Work Phone:______________________________

[—- PROVIDER: complete this section, fax to 407-812-5869 —————————— ]

Services requested:
□ Comprehensive sleep medicine consult. Includes polysomnogram & treatment as necessary.
□ Sleep study only, we will send your office a sleep study report.

Special Instructions/Pertinent Medical History:_____________________________________________

Physician Name (printed):_____________________________________________

Physician Phone:________________________________ Fax:________________________________

Physician Signature (required):_____________________________________________

Contacte con Nosotros

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