Office Enrollment Form

Please complete the form below to EnroLl your practice

  • You will also receive a Business Associates Agreement (BAA) to be completed before your account activation.

  • Once the Office Enrollment & BAA have been received we will activate your account within 1 business day.

  • Finally, expect contact from your Account Manager & Dental Sleep Coach to plan your orientation webinar.

Please contact Customer Service at 630-845-3483 or email Info@SleepTest.com if you need any assistance with the following form.

Address *
Address
Practice Phone *
Practice Phone
Back Office Phone
Back Office Phone
http://
Primary Doctor Name *
Primary Doctor Name
Skip the rest of the sections if there is only one Doctor at your location.
2nd - Doctor Name (if applicable)
2nd - Doctor Name (if applicable)
Skip the rest of the sections if there are only 2 Doctors at your location.
3rd - Doctor Name (if applicable)
3rd - Doctor Name (if applicable)
Skip the rest of the sections if there are only 3 Doctors at your location.
4th - Doctor Name (if applicable)
4th - Doctor Name (if applicable)
Skip the rest of the sections if there are only 4 Doctors at your location.
5th - Doctor Name (if applicable)
5th - Doctor Name (if applicable)
Anticipated Monthly Volume of Sleep Tests *
Sleep Medicine Training
Let us know who referred you so we can thank them for the opportunity.