FOR MORE INFORMATION CALL +1 801-937-4719

Online Referrals

Use the form below to refer someone for a free consultation with Sound Sleep Medical.

Physician Outreach

Paul Lopez

Call or text: 801-927-2031
Fax: 385-325-0185

Type of Refferals(Required)

Name(Required)

First Last

Email(Required)

example@example.com

Phone(Required)

Please enter the phone number of the person being referred. If you are referring yourself please enter your phone number here.

Date of Birth(Required)

MM-DD-YYYY

Referred By(Required)

Please enter the name of the physician or friend making the referral.

Referring Clinic(Required)

Please enter the name of the clinic making the referral.

Primary Insurance Company(Required)

Patient History(Required)

Max. file size: 3 GB.

Please upload patient Prescription and Baseline Polysomnography here. (we accept jpg, pdf and doc file formats)

I agree to be contacted via text, email or phone.(Required)

Yes

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Services

Custom Oral Appliances

Sleep Study at Home

Telemedicine

We have over
25 years of experience

Simply answer the following 5 questions Yes or No to see if you qualify.
If you have any questions or concerns please call: 801-762-6888.

Step 1 of 5

I wake up gasping for air during the night?(Required)

Online Referrals