Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Phone *

(###)

###

####

Preferred Weekday for Appointment *

***This does NOT guarantee an appointment on any specific date or time. We will do our best to accommodate an appointment on the next available weekday requested.

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred Appointment Time *

Morning (8am-12pm CST)

Afternoon (1pm-5pm CST)

No Preference

Additional Supplies to Purchase *

The manufacturer has advised that patients should be encouraged to obtain a new mask at the time they receive their replacement device. If you wish to obtain a new mask and filters, please make the applicable selections below. We will include your total estimated out of pocket cost that will be due for the supplies in your appointment confirmation email. If you do not indicate an insurance plan you wish to use, you will be quoted the self-pay rate.

DreamWear Standard Nasal Mask & Cushions

DreamWear Silicone Nasal Mask & Cushions

DreamWear Full Face Mask & Cushions

DreamWisp Nasal Mask & Cushions

Disposable Filters (pack of six)

I am declining any additional supplies at this time.

IF ORDERING SUPPLIES: Will you be using your insurance?

Yes, I would like to use my insurance.

No, I would like to use self pay.

IF ORDERING SUPPLIES: Mask Size (if applicable)

Small (S)

Medium (M)

Large (L)

I am declining a new mask at this time.

IF ORDERING SUPPLIES: Cushion Size (if applicable)

Small (S)

Medium (M)

Medium-Wide (MW)

Large (L)

I am declining a new mask at this time.

Complimentary 15-Minute Appointment with a Sleep Coach *

Yes

No