Patient Registration

First Name *

Last Name *

Sex *

Male Female

Date of Birth *

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(MM/DD/YYYY)

Height *

Feet Inches

Weight *

lbs

Neck Size *

Inches

Address1 *

Address2

Country *

select

City, State, Zip *

select

Email Address / UserName *
Confirm Email Address / UserName *	Check if Available

Password *
Confirm Password *

Phone Numbers *

select

Preferred Method

Add Another Phone Number

Health Insurance *

YesNo

Primary Insurance Information

Secondary Insurance Information

Plan Name *

Plan Name

Payer / Member Id **

Payer / Member Id

Policy# **

Policy#

Group# **

Group#

Plan Phone Number *

Plan Phone Number

Insured

First Name *

First Name

Last Name *

Last Name

Relation to insured *

select

Relation to insured

select

Terminal/Location ID *

I Don't Have a Terminal/Location ID

How did you hear about National Sleep Services?

select

Do you have a Commercial Drivers License (CDL)? *

YesNo

Date Physical is scheduled

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(MM/DD/YYYY)

Physician Details

In order to facilitate your sleep apnea screening, we need to know your primary care physician. Search our database to locate and select your primary care physician. If you do not find your physician in our database, please use the Add New button to supply his or her details.