Request a Sleep Center Appointment | Artesia General Hospital

YOUR INFORMATION

First Name

Last Name

Address

City

State

Zip

Phone

Email

Preferred Contact Method

Who is the patient?

Patient Name (if "Child" or "Someone Else")

Patient Date of Birth

MM/DD/YYYY

Insurance

Are you a new or existing patient?

New patient

Existing patient

Who is your primary care physician?

Have you had a sleep study before?

Yes

No

YOUR APPOINTMENT PREFERENCES

Which type of appointment are you requesting?

Sleep Consultation

Sleep Study

Some insurance companies require you to complete a sleep consultation before scheduling a sleep study. Your sleep consultation will be held with one of the providers at Artesia General Hospital's Memorial Family Practice.

Which time(s) of the day would you prefer your sleep consultation? (Check all that apply.)

Morning (7:00 to 11:00 a.m.)

Noon (11:00 a.m. to 1:00 p.m.)

Afternoon (1:00 to 4:00 p.m.)

Evening (4:00 to 6:00 p.m.)

Which day(s) of the week would you prefer your sleep consultation? (Check all that apply.)

Have you already had a sleep consultation?

Yes

No

Which day(s) of the week would you prefer your sleep study? (Check all that apply.)

What is the reason for your appointment?

Please provide any additional details about your request.

Consent Form

I acknowledge that this appointment request form requires me to provide protected health information (PHI), which will be used to schedule an appointment at Artesia General Hospital. By submitting this form, I consent to this information being disclosed to the scheduling office, as well as receiving notifications via my requested communication method for scheduling purposes. If email is my preferred method, I understand I may receive unencrypted emails from a scheduler that may contain PHI, such as my name and the type of appointment I have requested.

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Online Appointment Request – Sleep Center

Online Appointment Request – Sleep Center

Online Appointment Request – Sleep Center

YOUR INFORMATION

YOUR APPOINTMENT PREFERENCES

Location & Contact Info

Home Online Appointment Request – Sleep Center Online Appointment Request – Sleep Center

Online Appointment Request – Sleep Center

YOUR INFORMATION

YOUR APPOINTMENT PREFERENCES

Location & Contact Info

Home

Online Appointment Request – Sleep Center

Online Appointment Request – Sleep Center