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201 Sherman Avenue W, Fort Atkinson, WI 53538 ||
(920) 563-7323
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Doctor Referral Information
(920) 563-7323
Doctor Referral Information
Please use the form below to contact Dr. Stafford regarding a patient referral:
Patient Contact Information
Patient Name
*
Patient Phone Number
*
Patient Cell Phone Number
Email
*
Referring Doctor
*
Referral Information
Reason for Referral
*
Evaluation for TMJ Disorder
Evaluation for Sleep Disorder
Fabrication of sleep appliance due to snoring or CPAP intolerance
Both
TMJ Symptoms
*
Headaches
Migraines
Jaw Pain
Neck Pain
Ear Pain
Subjective hearing loss
Ear Congestion or blockage
Tinnitus (ringing in ears)
Vertigo (Diziness)
Clicking or popping in TMJ
Sinus pain pressure
Sleep Symptoms
*
Snoring
Constantly tired
Morning headaches
Diagnosed sleep apnea
Reported gasping at night (possible sleep apnea)
CPAP Intolerant
Patient Information
Has the patient had a sleep study?
*
Yes
No
Did you already instruct the patient to call us?
*
Yes
No
Other information or request:
*
Comments
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