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Our online self-referral form is the fastest way to book your appointment. Complete the information below and we will call you within 24-48 hours to complete your booking.

Physician Referrals

To refer a patient, please download our fillable PDF Patient Referral form and fax the completed form to 403 254 6693.

First Name^*

Last Name^*

Phone^*

Email^*

Gender^* Female Male

Birth Date (MM/DD/YYYY)^*

Address^*

City^*

Province^*

Postal Code^*

Alberta Health Care No.

Primary Sleep Concerns*

Obstructive Sleep Apnea Insomnia Excessive Daytime Sleepiness Shift Work/Jet Lag

Movement Disorders Parasomnia Athlete Safety Sensitive Occupation

Safety Sensitive Occupation*

Professional Driver Airline Pilot/Flight Staff Railroad Engineer/Conductor First Responder (EMS/Police/Fire)

Doctor/Nurse Oilfield Worker Other:

Additional medical information

* Required fields

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