Sleep study request — Dr Jason Edgar

1. Your contact details

Fields marked * are required. This form is intended for adults aged 18 and over.

Full name *

Contact number *

Email address

What would you like to arrange? *

Referring doctor, if applicableYour sleep concerns

Please leave out identity numbers, medical-aid membership numbers and other documents at this stage.

2. Tell us about your sleep

Thinking about the past four weeks, answer the questions below. If you are unsure, choose “Not sure”. You can still request an assessment.

Each “Yes” adds one to your symptom count. This is an original intake checklist, not a validated medical score. The count does not measure severity, estimate your chance of a diagnosis or decide whether you need a sleep study.

I confirm that I am aged 18 or older. *

3. Review your request

I agree to these details and screening answers being sent to Dr Edgar’s rooms to arrange contact about a sleep assessment. *

Your contact details and health information will be emailed to the practice to arrange and assess your request. Email is not end-to-end encrypted. Please provide only the information needed for this request. You may contact the rooms by phone instead. To ask about your information, contact reception@dredgar.co.za. This form does not create a confirmed booking.

Your request summary

A clinician will review your symptoms and decide whether testing is appropriate. You can request an assessment whatever your count, including zero. A zero count does not rule out a sleep disorder.

If you are sleepy when driving, do not drive or operate machinery and seek prompt medical advice. This form is not an emergency service.

Information prepared for reception

Your request will be emailed to reception@dredgar.co.za.