Service Request Form

Download our Service Request Form (prescription)

Download Fillable .pdf form 

You can download this version of the form and fill out the patient information, services requested, etc. on your computer. 

When you click the link, the form will download automatically to your downloads folder.

Download NON-Fillable .pdf form 

This form prints a little better than the fillable version, if you plan to fill out the form by hand. 

When you click the link, the form will download automatically to your downloads folder. 

Fax the completed form to (877) 855-6227 or email orders@sleepdr.com

  • Home Sleep Testing (HST)
  • CPAP Device Set-up
  • CPAP replacement supplies

The form includes the HCPC/CPT codes for services.