Forms

Forms for Physicians

• Sleep Study Order Form (PDF 60kb)
• PFT Order Form (PDF 10kb)

To have your Sleep Study/Pulmonary Function Test (PFT) completed with Sleep Diagnostic Centers of New Mexico, LLC, we will also need the following faxed to our office (along with the order form) 575-622-1720:

• Copy of insurance card
• Doctor's notes with reason for study and/or history and physical
• Prior authorization from insurance company if required by insurance company

Forms for Patients

New patients for office visit

Please fill out following forms and bring them with you for your appointment. If you have any X-ray and Cat scans done at a hospital other than Eastern New Mexico Medical Center, please bring the films or CD with you. Please have your doctor fax your recent labs and office notes to our office

Please download and bring these forms filled out for your first office visit.

• Consent to Treat (PDF 25kb)
• Medical History (PDF 51kb)
• Patient Information (PDF 60kb)

• Epworth Sleepiness Scale (PDF 50kb)

 Patients scheduled for sleep study:PLEASE READ BEFORE DOWNLOADING FORMS

IF YOU ARE UNAMBULATORY OR NEED ASSISTANCE TO TRANSFER TO AND FROM BED, YOU WILL NEED TO BE ACCOMPANIED BY FAMILY MEMBER/FRIEND WHO HELPS YOU IN THOSE FUNCTIONS AT HOME. THIS PERSON WILL HAVE TO SPEND THE NIGHT WITH YOU IN THE LAB. YOUR APPOINTMENT WILL BE CANCELLED AFTER ARRIVAL TO THE LAB BY THE TECHNICIAN IF THIS REQUIREMENT IS NOT MET.

Please download and bring these forms filled out for your sleep study.

• Consent to Treat (PDF 25kb)
• Patient Letter (PDF 14kb)
• Epworth Sleepiness Scale (PDF 50kb)
• Sleep Questionnaire (PDF 84kb)
• Permission to Videotape (PDF 30kb)

We look forward to helping you get a great night's sleep!