PATIENT NAME:
DOB:
EMAIL:
HOME
SLEEP
TEST
CONSENT
FORM
I hereby provide consent to undergo the Home Sleep Test tonight as ordered by my
physician. I acknowledge that I have been given written and illustrated instructions
for reference, a verbal explanation from our Sleep Disorders Center staff at the
time of pick up, and a demonstration was given to ensure the ring device connects
to the application on the Smart Phone.
I am aware of the pick-up time for my test and it is picked up at the office located at
4235 Kings Hwy, Port Charlotte at the back of the building at the garage.
I am aware that the Home Sleep Test equipment must be returned the following
business day morning no later than 9:00 AM to the front desk.
I acknowledge that the home sleep test is the property of Pulmonary Sleep &
Critical Care Specialists and that failure to return this equipment at the time
designated will result in a charge of $200.00 per day until the equipment is
returned.
I understand that if a device is returned damaged, I am responsible for any cost
incurred with replacing the device and/or components which have been lost,
damaged, or not returned.
I AGREE AND UNDERSTAND THAT IF I DO NOT HAVE THE SLEEP IMAGE
APPLICATION DOWNLOADED ON MY PHONE PRIOR TO PICK UP, I WILL BE ASKED
TO RESCHEDULE MY APPOINTMENT.
Patient Signature
Date
4235 Kings Highway, Suite 103, Port Charlotte, FL33980 • Phone: 941-613-1777 • Fax: 941-613-1779
25086 Olympia Avenue, Suite 300, Punta Gorda, FL33950 • Phone: 941-205-5300 • Fax: 941-205-5302
14942 Tamiami Trail, Unit B, North Port, FL 34287 • Phone: 941-876-4415 • Fax: 941-876-4357