Sleep Dentistry Referral Form

Great Lakes Sleep Care

Address: 933 3 Mile Rd N.W. Suite 110
Grand Rapids, MI 49544

Phone: (616) 784-6300

Fax: (616) 784-9303

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Part 1: Referring Physician and Clinic Information

Referring Physician*

Clinic/Department*

Address*

Phone*

Fax

Email*

Reason for Referral*

(Please Specify)*

Part 2: Patient Information

Patient Name*

Date of Birth*

Patient Phone*

Patient Email*

Primary Insurance

Insurance Company Name

Member ID

Date of Last Sleep Study*

Diagnosis*

ICD-10 Code

Diagnosis Type*

(Please specify)*

Part 3: Required Medical Records

Please provide the following documentation to ensure a seamless evaluation:

A copy of the most recent sleep study report (polysomnography or home sleep apnea test)

Max. file size: 64 MB.

A copy of the patient's most recent physician notes related to their sleep apnea.

Max. file size: 64 MB.

Insurance information (copy of front and back of insurance card).

Max. file size: 64 MB.

Oral Appliance Rx

Max. file size: 64 MB.

Authorization for Release of Medical Information*

By sending this referral, the referring provider acknowledges that they have obtained the patient's consent to release the necessary medical information to Great Lakes Sleep Care for the purpose of a sleep dentistry consultation and treatment.

Part 4: Physician Signature

Physician Signature:

Date

At Great Lakes Dental Care, we remain dedicated to serving West Michigan by helping patients maintain a healthy smile that lasts a lifetime. Learn more about our Grand Rapids dentists here →

Dental Services

Family Dentistry

Dental Implants

Cosmetic Dentistry

Teeth Whitening

Oral Surgery

Office Hours

Mon: 7 am – 6 pm

Tues: 7 am – 6 pm

Wed: 7 am – 6 pm

Thur: 7 am – 6 pm

Fri: 7 am – 5 pm

Contact Info

Great Lakes Dental Care

933 3 Mile Rd N.W. Suite 110
Grand Rapids, MI 49544

616.784.6300

[email protected]

Disclaimer: This website is provided for informational and educational purposes only. No doctor/patient relationship is established by your use of this website. No diagnosis or treatment is being provided. The information contained here should be used in consultation with a doctor of your choice. No guarantees or warranties are made regarding any of the information contained within this website. This website is not intended to offer specific medical, dental or surgical advice to anyone. Furthermore, this website and Great Lakes Dental Care take no responsibility for websites hyperlinked to this site and such hyperlinking does not imply any relationships or endorsements of the linked websites.

Great Lakes Sleep Care Sleep Dentistry Referral Form