SCREENING FORM

For Patients with Head, Neck and Facial Pain & Sleep Disordered Breathing/Apnea

When your patients experience one or more of these symptoms, they should have a thorough evaluation by a dentist trained in TM and Sleep. We will be happy to assist you in diagnosis and treatment for possible Craniomandibular, Temporomandibular or Sleep Disordered Breathing/Apnea.

Patient Information:

Name:
Phone:
E‐mail:
Address:

Referred by:

Use your mouse cursor or the tip of your finger to sign below

Name:
Date:
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TMJ & Sleep Therapy Centre of Raleigh-Durham

Charles Ferzli, D.D.S.

DABCP, DABCDSM, FAACP
1150 NW Maynard Road. #140
◆ Cary, NC ◆ 27591

919.323.4242

www.RaleighTMJandSleep.com

  Instructions:

  1. Mail or fax a copy to:
    TMJ & Sleep Therapy Centre
  2. Give a copy to the patient
  3. Keep a copy for your files