Please fill out and submit the form below. Fax patient records to:
520-229-9107, attn: Medical Records
You may also email patient records and referrals to:
patientforms@pimalung.com
Please check all appointment types that apply to this patient.

PATIENT INFORMATION

Patient Name:
Date of Birth:
Home Phone:
Mobile Phone:
Work Phone:
Street Address:
City:
State:
Zip Code:
Email:
Social Security #:
Primary Care Doctor:
Primary Care Phone:
Comments:

SLEEP STUDY (PSG)

Self Pay Sleep Study will be $2250.00. This rate includes the following:

1st Phase: Initial Consultation with Dr Amitab Puri

2nd Phase: Sleep Study at Pima Lung Sleep at either lab in

 Tucson
 Green Valley

3rd Phase: Follow up to review Sleep Study & any further recommendations from Dr Amitab Puri

If patient requires a "2nd" sleep study within 90 days of the original study done at Pima Lung & Sleep, the patient will be charged at discounted rate of $750.00.