New Patients - DuPage Sleep Solutions

First Name *

Last Name *

Date of Birth *

ADDRESS

Address *

City *

State *

Zip *

CONTACT INFO

Email

Phone *

Is it okay if we text you appointment updates and reminders? *

Yes
No

APPOINTMENT INFO

What is the reason for your visit? *

How did you hear about us?

Were you referred to us by a physician?

Yes
No

Physician's Name

Physician's Group or Office Name

Do you have medical insurance?

Yes
No

Insurance Company Name

Group Number

Subscriber's Full Name

Subscriber's Date of Birth

Subscriber's Social Security Number

Subscribers Relationship to Patient

I certify that I, and/or my dependent(s), have insurance coverage with the insurance company listed above and assign directly to DuPage Sleep Solutions all insurance benefits. If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

DuPage Sleep Solutions may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for releated services. This consent will end when my current treatment plan is completed or one year from the date indicated below.

I agree to the Assignment and Release Terms

Today's Date

Sleep Information

Have you ever had a sleep study done? *

Yes
No

When was your last sleep study?

If your sleep study has been done within the past two years, please have your physician fax it to us at 630-355-7428.

Do you currently wear a CPAP? *

Yes
No

How often do you wear a CPAP? (Nights, Times, etc.)