Forms & Referrals

Choose the option that matches you. New patients complete intake paperwork ahead of their first visit. Healthcare providers refer patients into our care directly.

Patients

New Patient Paperwork

Complete your intake forms securely online before your first visit, so we can spend our time with you focused on what matters.

Personal & insurance information
Medical & surgical history
Current medications & allergies
Sleep, breathing, and symptom history
HIPAA acknowledgment & consent

Begin patient forms Providers

Refer a Patient

Healthcare providers can refer patients to our team directly. We coordinate with the referring office on records, evaluation, and ongoing care.

Referring provider & clinic information
Patient demographics & reason for referral
Records, imaging, prior evaluations
Coordinated communication back to the referring office
Same-week response on referrals

Submit referral

For new patients

New Patient Paperwork

Complete the fields below to get started. Once submitted, our team will reach out within one business day to schedule your consultation and provide remaining intake forms.

Patient first name *

Patient last name *

Date of birth *

Patient is *

Email *

Phone *

Insurance carrier (if applicable)

Primary concern *

Tell us briefly what brought you here

How did you hear about us?

We'll reach out within one business day.

By submitting this form, you agree to be contacted by BreatheWell Institute regarding your inquiry. This form does not transmit Protected Health Information; full medical history will be collected through our secure patient portal after initial contact. See our HIPAA notice and privacy policy.

For healthcare providers

Refer a Patient

Pediatricians, dentists, lactation consultants, speech-language pathologists, sleep medicine physicians, ENT, and primary care: please use this form to refer a patient. We respond to all referrals within one business week and coordinate communication back to your office.

Referring provider

Provider name *

Practice / clinic *

Specialty *

NPI (optional)

Provider email *

Provider direct phone *

Patient information

Patient first name *

Patient last name *

Patient DOB *

Best contact phone for patient

Reason for referral *

Specific consult requested

Records you can send (please email separately)

We respond within one business week.

Records may be transmitted to records@breathewellinstitute.com or by fax to (806) 353-1055 (placeholder). All transmissions handled in accordance with HIPAA. Please obtain patient authorization to share PHI before transmitting records.