Patient Questionnaire / HIPPA / PHI / Photo Follow Up Patient


Fill out and submit Epworth Sleepiness Score here

Photos of your driver’s license and insurance cards if changed (front and back)

Please take a photo (by mobile phone)

Email the photos of your driver’s license and insurance cards

Email all photos to
On the subject line type your name and date of birth

FOR FOLLOW UP PATIENTS (within 3 years of last appointment)

(only if there are any changes)

Patient Profile Demographics

(if there are any changes in your address, phone, email, insurance, PCP etc.)

Fill Out and Submit Patient Profile Demographic Here

Fill Out and Submit the PHI Disclosure Form Here

FOR FOLLOW UP PATIENTS (returning after 3 years)

Please click here for Adult New Patient

Please click here for Pediatric New Patient