## Provider Referral Form

Complete the form below to submit your referral.

#### Provider Information

Provider Name\*

Clinic/Practice Name\*

Provider Email\*

Provider Phone

#### Patient Information

First name\*

Last name\*

Email\*

Phone number\*

#### Reason for Referral

Please select reason InsomniaSleep ApneaSleep AnxietyOther

Other reason

By sending this referral, I confirm that I have secured my patient’s consent for sharing their personal data with Sleep Reset, have provided them with the required notices, and understand that Sleep Reset’s privacy policy offers additional information.

# Thank you!

Your referral has been received.

Our team will contact your patient within 24 hours.

Oops! Something went wrong while submitting the form.

This referral form follows the standards set by the U.S. Health Insurance Portability and Accountability Act (HIPAA) to protect sensitive patient health information. Always check your local compliance laws before sharing patient health information.

Fax: +1 (984) 888-8385

## Sleep Program

[Insomnia Program](https://www.thesleepreset.com/cbti-based-program) [Clinician Visit](https://www.thesleepreset.com/sleep-reset-virtual-clinician-visits) [Home Sleep Test](https://www.thesleepreset.com/home-sleep-study) [Oral Appliance Therapy](https://www.thesleepreset.com/sleep-apnea-oral-appliances) [Wall of Reviews](https://www.thesleepreset.com/reviews) [Sleep Clinicians & Coaches](https://www.thesleepreset.com/sleep-providers) [FAQ](https://www.thesleepreset.com/looking-for-help) [Gift Sleep Reset](https://thesleepreset.com/gift)