ApnoMed Referral Network

Refer a Patient

If your patient needs help getting fitted for a sleep apnea oral appliance, submit their information below. ApnoMed will match them with a certified ApnoDent provider near them and coordinate next steps directly with your office.

Referring Clinician

Your Name* (required)

Title / Specialty* (required)

Practice / Clinic Name* (required)

Office Phone* (required)

Office Email* (required)

NPI Number

Patient Information

Patient Name* (required)

Date of Birth* (required)

Patient Phone* (required)

Patient Email* (required)

Patient City* (required)

Patient State* (required)

Patient ZIP Code* (required)

Used to match the closest certified ApnoMed provider.

Clinical Details

Has the patient had a sleep study / OSA diagnosis?* (required)

Yes, diagnosed

Study pending

Not yet tested

Unknown

AHI / Severity (if known)

Reason for oral appliance referral (select all that apply)

CPAP intolerant / non-compliant

Patient prefers oral appliance therapy

Snoring and sleep apnea

TMJ/grinding

Other

Additional Notes for the Provider

Urgency* (required)

By submitting this form, you confirm you have appropriate authorization to share this patient's information with ApnoMed for the purpose of care coordination and provider matching, consistent with applicable HIPAA requirements. ApnoMed will use this information solely to route the referral to a certified ApnoDent provider and follow up with your office.

I confirm I am authorized to submit this patient referral.* (required)

A confirmation will be sent to your office email.