PACKETS FOR DOWNLOAD
** Must Know Your MRN to Use This Link Directly. **
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
Telemedicine Consultation 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 the patient is taking.
- Sleep questionnaire.
FORMS FOR DOWNLOAD
Bed Partner Form:
Oftentimes, your bed partner 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.
Epworth Sleepiness Scale:
The standard scale for making sleep assessments.
This 8 questions self-administered sleep survey gives our clinicians a better understanding of your general daytime sleepiness levels.
Information and Patient Releases:
Additional information and sleep study patient release form.
To help us better diagnose and treat your sleep disorder fill out this detailed questionnaire about your sleep habits,
medical history, day and night symptoms, and other questions to better help our clinicians treat you.
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.
Prior Sleep Study History:
If you have previously had a sleep study, please tell us more about your experience by filling out this questionnaire.
Self Referral Form:
When you are interested 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 your 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.
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.
This obstructive sleep apnea screener helps determine your risk of OSA.
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.
Maps To Our Facilities
Need help finding us? Click here for a list of our locations.