PACKETS FOR DOWNLOAD adobe-pdf-icon-logo-vector-01-347012-edited.png


Complete Patient Packet
Includes the following forms:

  • Patient Registration Form
  • Financial Policy
  • Authorization for Release of Health Information
  • Private Health Information Disclosure
  • Notice of Privacy Practices
  • Patient Release Forms
  • Patient Questionnaire
  • Bed Partner Questionnaire
  • Sleep Diary
  • Instructions for Sleep Study 

Download Complete Patient Packet  

Telemedicine Consulation Packet
Includes the following forms:

  • Consent for telemedicine consultation with Dr. Reinoso.
  • Authorization of release of medical information.
  • Patient information.
  • Patient insurance information.
  • Family medical history.
  • Listing of current medications patient is taking.
  • Sleep questionnaire.

Download The Consultation Packet




 FORMS FOR DOWNLOAD adobe-pdf-icon-logo-vector-01-347012-edited.png


 

Bed Partner Form

Oftentimes your bedparnter knows more about your sleeping habits than you do. For this reason, we want to hear from them so they can fill us in on any details about your sleeping that you may be unaware of.

 Download Bed Partner Questionnaire

Epworth Sleepiness Scale

The standard scale for making sleep assessments. This 8 question self-administered sleep survey gives our clinicians a better understanding of your general datyime sleepiness levels.

Download The Epworth Sleepiness Scale

Pediatric Questionnaire

To help us better diagnose and treat your little one's sleep disorder fill out this detailed questionnaire about their sleep habits, medical history, day and night symptoms, and other questions to better help our clinicians treat your child.

Download The Pediatric Questionnaire

Self Referral Form

When you are insterested in working with a board certified sleep doctor but do not have a direct referral from a provider this is the form you need.  Once the quick one page form is completed, send it back to the Alaska Sleep Clinic of you choice, we will forward your information to our medical director and we will contact you for further information on setting up your appointment based on the doctor's recommendations.  

 Download Self Referral Form

Sleep Diary

Start keeping track of your sleep troubles by downloading a sleep diary. In the diary you can record important information that can give both you and your primary care physician a better understanding of your sleep habits, and where any problems may lie.

In the diary, record important bits of information such as what time you went to bed, how long it took to fall asleep, how long you slept, how difficult it was to wake in the morning, how tired you felt the next day, and list amount of caffeinated or alcoholic beverages consumed during the day as well as medications you may have taken.

Download The Sleep Diary

Testimonial Form 

Want to share your experience about living with a sleep disorder and the treatment you received at The Alaska Sleep Clinic? Download the Testimonial form and share your journey with others.

Download The Testimonial Form


Maps To Our Facilities

Need help finding us? Click here for a list of our locations.

View maps to our locations

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