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The referral form for sleep studies consists of four sections
Section A: Patient Information /
Physician Information
The name, address, phone number(s), date of birth, and
Health Card Number (HCN) of the patient to be referred to the
facility must be completed.
Section B: Physician Information
The names of the requesting, referring, and family
physicians, including the requesting physician's OHIP Billing
Number are to be completed in full. The requesting physician
must provide a signature and date the request.
Section C: Reason(s) For
Referral/Pertinent Medical History
Symptoms Leading to Referral
The requesting physician must provide as much information as
possible in this section of the referral form. This information
includes a diagnosis, pertinent medical history, symptoms
leading to referral, current medications, surgical history, CPAP
or supplemental oxygen use, and any additional information that
may be essential in assessing and providing the correct sleep
study for the patient.
In order
to prioritize patients based upon the severity of their
symptoms, the referring physician must declare the relative
level or urgency assigned to the referral.
Acceptable Indications For Sleep Study
»
Suspected
sleep apnea
»
Snoring
accompanied with any other indications
»
Excessive
Daytime Sleepiness
»
Witnessed
Apneas
»
Suspected
Periodic Limb Movement (PLM)/Restless Leg Syndrome (RLS)
All referrals for sleep studies are to be reviewed by the
site sleep physician(s) prior to patient booking.
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