PATIENT REFERRAL


Refer a Patient to Carolina TMJ & Sleep Solutions

Thank you for referring your patient to Carolina Sleep & TMJ Solutions. We’re committed to making referrals easy and to treating your patients with the personalized care they need.


Please complete the form on this page to begin the referral process. Scroll down to see both the Sleep referral form and the TMJ referral form.

SLEEP REFERRAL FORM

REFERRING PROVIDER INFORMATION


PATIENT INFORMATION


TREATMENT RECOMMENDATION 


The patient exhibits the following symptoms and co-morbidities associated with his/her diagnosis of Obstructive Sleep Apnea:


PRESCRIPTION


DURATION: Lifetime         DIAGNOSIS CODE: G47.3

TMJ REFERRAL FORM

REFERRING PROVIDER INFORMATION


PATIENT INFORMATION


PATIENT HISTORY & CHIEF COMPLAINTS


The patient exhibits the following symptoms and chief complaints:


Patient History: Please include events such as car accidents, surgeries, or cause/onset of symptoms as applicable