Etobicoke
Brampton
Sleep Clinic
416-742-0680
Home
About Us
About Us
Take a Tour
FAQ
Educational Videos
Services
Services
Questionnaires
Sleep Disorders
For Patients
Referral Form
PSG Form
Dr. Arina Bingeliene Consultation Form
Dr. Dove Consultation Form
Dr. Kukreja Consultation Form
Dr. Shayan Makvandi Consultation Form
Sleep Diary
Epworth Sleepiness Scale
Uninsured Services in Ontario
Complaint Process
Forms & Links
Brochures
Book Online
Contact Us
Sign In
Book Online
Book Online
Please Complete All Sections in Full
Patient name:
Sex:
Male
Female
D.O.B.
HCN
Version Code
Address:
Postal Code
Home#
Bus.#
Family Physician
SERVICES REQUESTED FOR:
SLEEP STUDY AND CONSULT
SLEEP STUDY ONLY
CONSULT ONLY CPAP FOLLOW UP
(Consult Advisable)
Has patient had a sleep study done previously?
No
Unknown
Yes, study was done on
REASON FOR REFERRAL
Snoring
Non-Restorative Sleep
Fibromyalgia
Witnessed Apnea
Hypersomnolence/fatigue
Narcolepsy / Sleepiness
Insomnia
Morning Headache
CPAP follow up
Parasomnia
Nocturnal Seizures
Post Surgery
Oral Appliance
MSLT/MWT
Periodic Legs Movements/Restless Legs
Others:
PAST MEDICAL HISTORY:
Asthma
Angina
Depression
Parkinson’s
COPD
Cardiac Arrhythmias
Anxiety
Dementia
Hypertension
Obesity
Seizures
Bruxism
CAD
Diabetes
Stroke
GERD
Heart Failure
Alcoholism
Other Problems:
Current Medications:
REFERRING PHYSICIAN
Billing#
Name:
Mailing address:
Postal Code:
Phone#:
Fax #:
Date:
Signature / Attestation*
(Draw your signature - legally binding)
Sign in the box above using your mouse or finger (on touch devices)
Clear Signature
I understand that my electronic signature, whether drawn or typed, is the legal equivalent of my manual/handwritten signature and that I am consenting to the terms and conditions of this document.
Reset
Submit
© 2026 Etobicoke Brampton Sleep Clinic. All rights reserved
Follow Us