Patient Referral
  1. Which facility are you sending refferal to?(*)
    Invalid Input
  2. Patient Name:
    Invalid Input
  3. Date of Birth:
    Invalid Input
  4. Gender:
    Invalid Input
  5. Address/City/Zip:
    Invalid Input
  6. Phone:
    Invalid Input
  7. Mobile/Alternative Phone:
    Invalid Input


  8. Suspicious Symptoms:











    Invalid Input
  9. Other Symptoms:
    Invalid Input


  10. Suspected Diagnosis:






    Invalid Input
  11. Other:
    Invalid Input


  12. Please Indicate Service(s) Requested:








    Invalid Input


  13. Please indicate if you, the referring physician, will handle all follow-up care:

    Invalid Input




  14. For Patient Referrals for Sleep Studies without Initial Consultation: My signature below attests to the fact I, the referring physician, have evaluated this patient by sleep-appropriate medical history (signs and symptoms, symptom duration, sleep hygiene survey) and physical examination (focused cardiopulmonary and upper airway examination, neck circumference, BMI) and have concerns for the presence of the above listed symptom(s) and suspected diagnoses. Documentation of my evaluation is included with this request. All requirements and qualifications are met for the requested testing.
  15. Physician's Name:
    Invalid Input
  16. NPI#:
    Invalid Input
  17. Phone:
    Invalid Input
  18. Fax:
    Invalid Input
  19. Email:
    Invalid Input


  20. Please fax order form, patient demographics, insurance card, and pertinent clinical notes to preferred location. Note: In Anchorage and Fairbanks, all consultations will be conducted by Denali Asthma and Pulmonary LLC.

Our Offices

SLEEP CENTERS OF ALASKA
Anchorage Office
TudorMed Plaza
2421 East Tudor Road, Suite 102
Anchorage, Alaska 99507

Phone: 907-677-8889
Fax:     907-677-8886
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

 

 

SLEEP CENTERS OF ALASKA
Wasilla Office
351 West Parks Highway, Suite 100
Wasilla, Alaska 99654
Phone: 907-357-8410
Fax: 907-357-8423
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

SLEEP CENTERS OF ALASKA
Soldotna Office

35670 Kenai Spur Highway, Suite 103A
Soldotna, AK 99669
Phone: 907-260-9520
Fax:     907-260-9510
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

SLEEP CENTERS OF ALASKA

Fairbanks Office
3202 International Street, Suite 200
Fairbanks, AK 99701

Phone: 907.328.0582
Fax:     907.328.0586
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.