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Peoria, IL – Patient Referral Form

For Our Referring Physicians

Below is our online doctor referral form that will quickly help you refer a patient to our office. We will reach out to schedule a consultation with your patient on our next business day.

If you have any questions, please call
New Patients: (309) 981-7235 | Existing Patients: (309) 243-8980

Home » Peoria, IL - Patient Referral Form

In addition to completing the form below, please fax the following medical records to our HIPAA Secure Fax: (866) 474-4113

For Obstructive Sleep Apnea Consultations, please fax:

1. Baseline Sleep Study With Diagnosis and Interpretation

2. A Signed Prescription/DME Order Containing:

  • Description: Mandibular Advancement Device
  • Quantity: 1
  • Frequency: Nightly/While Sleeping
  • Duration: Lifetime
  • Please Note: Original Device or Replacement
  • If for Replacement: Current Device Used and Reason for Replacement

3. Physician Chart Notes Including:

  1. Encounter Notes Prior to the Order of Baseline Sleep Study
  2. Discussion of Sleep Study Results and Treatment Recommendations
  3. Any Previously Tried/Failed/Contraindicated Therapy Attempts
  4. Patient’s Intolerance or Refusal of CPAP (including date and reasons if discontinued)
  5. Recommendation or referral for Oral appliance therapy

For Temporomandibular Joint Disorder Consultations, please fax:

1. History/Physician Chart Notes
2. Any Previously Tried and Failed Therapy Attempts

If you have any questions, please contact us at: (309) 981-7235
Fax Medical Records to HIPAA Secure Referral Fax: (866) 474-4113

In addition to completing the form below, please fax the following medical records to our HIPAA Secure Fax: (866) 474-4113

For Obstructive Sleep Apnea Consultations, please fax:

1. Baseline Sleep Study With Diagnosis and Interpretation

2. A Signed Prescription/DME Order Containing:

  • Description: Mandibular Advancement Device
  • Quantity: 1
  • Frequency: Nightly/While Sleeping
  • Duration: Lifetime
  • Please Note: Original Device or Replacement
  • If for Replacement: Current Device Used and Reason for Replacement

3. Physician Chart Notes Including:

  1. Encounter Notes Prior to the Order of Baseline Sleep Study
  2. Discussion of Sleep Study Results and Treatment Recommendations
  3. Any Previously Tried/Failed/Contraindicated Therapy Attempts
  4. Patient’s Intolerance or Refusal of CPAP (including date and reasons if discontinued)
  5. Recommendation or referral for Oral appliance therapy

For Temporomandibular Joint Disorder Consultations, please fax:

1. History/Physician Chart Notes
2. Any Previously Tried and Failed Therapy Attempts

If you have any questions, please contact us
New Patients: (309) 981-7235 | Existing Patients: (309) 243-8980
Fax Medical Records to HIPAA Secure Referral Fax: (866) 474-4113