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Sleep Apnea
Snoring and Sleep Apnea
Top 10 Tips on How to Stop Snoring
QuietNite Snoring Laser Airway Improvement
Sleep Apnea and Snoring Devices
Sleep Apnea and Snoring FAQ
FREE Consultation Sleep Apnea and Snoring
Snoring Prevention QuietNite DEKA Laser
Myofunctional Therapy
TMJ Pain Relief
TMD and TMJ Treatments at Aligned Healing!
TMJ Orthotics Near You on Clermont
Airway Orthodontics and MARPE
Physical Therapy
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Benefits of Candid Clear Aligners
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Discover Healing
Advanced Technology
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Sleep Apnea
Snoring and Sleep Apnea
Top 10 Tips on How to Stop Snoring
QuietNite Snoring Laser Airway Improvement
Sleep Apnea and Snoring Devices
Sleep Apnea and Snoring FAQ
FREE Consultation Sleep Apnea and Snoring
Snoring Prevention QuietNite DEKA Laser
Myofunctional Therapy
TMJ Pain Relief
TMD and TMJ Treatments at Aligned Healing!
TMJ Orthotics Near You on Clermont
Airway Orthodontics and MARPE
Physical Therapy
Clear Aligners
Benefits of Candid Clear Aligners
Clinical Hypnosis
Discover Healing
Advanced Technology
Blog
Products
Contact
Careers / Employment
Professional Referrals
About
schedule a visit
Work With The Best Airway Health Team in Denver!
Subhead: Dr. Atousa Safavi and her team welcome the chance to receive professional referrals for patients who are suffering from sleep apnea, TMJ and other airway health disorders
Please complete the referral form below and click submit
Provider Name
Practice Name
Provider Phone
Provider FAX
Patient Information
Patient Name
Date of Birth
Patient Phone
No Insurance
Attach a copy of insurance card (front and back)
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Reason(s) for Referral
Obstructive Sleep Apnea
CPAP Intolerance
Day Time Tiredness
Snoring
Insomnia
Headaches
Mood Disorder
Hormone Imbalance
Hypertension
Diabetes
Chronic Pain
Weight Gain
Other
Service(s) Requested
Sleep Consultation
Myofunctional Therapy
Oral Appliance
TMD Evaluation
Sleep Treatment History
Has the patient completed sleep test?
Yes
No
If yes, attach complete sleep test
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Has the patient attempted CPAP?
Yes
No
If yes, attach chart note indicating dates of use and intolerance reasons
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Additional Notes
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Schedule Your Visit
You can call or fill out the form below
Please select the type of appointment or free consultation you need
I Just Need a Regular Appointment (NOT a FREE Consultation)
Invisalign FREE Consultation
Candid FREE Consultation
Cosmetic Dentistry FREE Consultation
Snoring and Sleep Apnea FREE Virtual Consultation
TMJ & TMD FREE Virtual Consultation
I Have a Dental Emergency-Contact me ASAP! (NOT a FREE Consultation)
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Last name
Email
Phone
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