Consultation SLEEP BETTER COLUMBUS TMJ Consult Sleep Apnea Consult Request a Benefit Analysis Sleep Apnea Consult Form Sleep Apnea Consult Name * Last Name * Phone * Email * Contact preference Phone Email Best contact time Have you been diagnosed with Sleep Apnea? * Yes No Approximate date of diagnosis Do you wear a lower denture? * Yes No Have you tried CPAP? * Yes No Medical Insurance carriers Aetna Cigna Humana UnitedHealthcare Medicare Ohio Healthy OtherOther Insurance provider phone number Do you carry a supplemental Medicare policy? Yes No Subscriber name Subscriber date of birth Subscriber ID How did you hear about us? * Website / Google Facebook Medical Doctor Dentist Another Patient Our Staff Radio 97.1 Radio 610 Kroger Kiosk Word of Mouth OtherOther Submit If you are human, leave this field blank. Office Address 1335 Dublin Rd, Suite 100BColumbus, OH 43215 Phone & Fax Phone: (614) 777-7350 Fax: (888) 390-0424