BCOH Sleep Apnea Referral

Referrals

For physicians who want to refer their patients to our office for treatment for sleep apnea, please download and fill out our referral form.

    Patient's Information


    Patient's Email


    Patient's Address

    Patient's Phone Number


    Patient's DOB


    Requesting Physician's Information



    Sleep Study Available:


    YesNo

    Reason for referral (Mark all that apply)

    Diagnosis:


    Obstructive Sleep Apnea (ICD 327.23)Hypersomnia due to Sleep Apnea (ICD 780.53)Insomnia due to Sleep Apnea ( ICD 780.51)Other , unspecified (ICD 780.57)

    Baseline Data (without CPAP or Oral Appliance)

    AHI


    RDI


    Lowest Desaturation (SpO2)


    T90

    Therapies attempted:


    CPAP

    Surgery
    YesNo

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    Request A Presentation

    For physicians want to learn more about oral appliance therapy, please request a presentation by contacting us.

    Phone: (617) 536-4620
    Email: bcoh@bcoh.com

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