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


                 New Patient Electronic Forms

** 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                                                                                  sleep-deprivation
  • 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:

Often times, 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.

 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

         

Information and Patient Releases:

Additional information and sleep study patient release form.   

Download The Patient Release Form

 

 

  Patient Questionnaire:

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. 

Download The Patient Questionnaire

           

 

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

       

 Prior Sleep Study History:

If you have previously had a sleep study, please tell us more about your experience by filling out this questionnaire.

 

Download The Prior Sleep Study History Form

 

 

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 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.

 

Download The Sleep Diary

 

                                                                                                       

                                                                                                   Stop Bang Questionnaire:                                                                                                          

This obstructive sleep-apnea screener helps determine your risk of OSA.

 

Download The Stop Bang Questionaire                                                                                                                 

 

  No Show Billing Policy

 

 

 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

NOTE:  adobe-pdf-icon-logo-vector-01-347012-edited.png PDF files require Acrobat Reader to view.  If you do not have Acrobat Reader, you can download a free copy here.