Aura Orthodontics – Sleep Apnea Appliance Referral

Thank you for considering us as your orthodontic partner for sleep apnea care. Please complete the form below to submit your referral, and our team will be in touch with you shortly.

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Patient Contact Information

Patient mame(Required)

First Last

Patient email(Required)

Patient phone(Required)

Preferred contact method

Preferred consultation days

Preferred consultation time

Date of birth(Required)

Emergency contact

Address

Street address Address line 2 City Province Postal code

Insurance Information

Insurance provider name

Policy/member ID number

Group number (if applicable)

Subscriber name

Date of birth

Diagnosed Sleep Disorder

Diagnosed sleep disorders

Sleep Study Documentation

Sleep study date (must verify validity duration i.e how long is a sleep study good for until insurance requires a more recent one?)

Facility or provider name

AHI / RDI / ODI

Please attach patient's sleep study report

Accepted file types: pdf, jpg, png, Max. file size: 200 MB.

Download Sleep Study Report (PDF)

Referring Doctor

Referring doctor(Required)

Your phone(Required)

Your email(Required)

Which orthodontist would you like to refer this patient to(Required)

Which Location would you like to refer this patient to(Required)

Reason for referral

Attach dental imaging (Limit 8 files)

Drop files here or

Max. file size: 200 MB, Max. files: 8.

Aura Orthodontics – Sleep Apnea Appliance Referral

Patient Contact Information

Insurance Information

Diagnosed Sleep Disorder

Sleep Study Documentation

Referring Doctor

Ready to Start Your Orthodontic Treatment?

GUILDFORD CLINIC

SCOTTSDALE CLINIC

LANGLEY CLINIC