Select a Location and Date

The sleep study kit will be delivered to your clinic on your chosen date *

Select a Date for the sleep study

(Please pick up the kit during the clinic's opening hours.) (60 minutes)
Ensure you are available to pick up the kit on your chosen date and return it the following day. Unfortunately booking dates cannot be changed afterwards.

Select a Study type

Choose one or more add-ons

Your clinic's name *

Your clinic's address *

Street address *Street address line 2

City *

State *

Postcode *

Country

Personal Information

First Name *

Last Name *

Date of birth *

Email Address *

Mobile Number *

Sleep Questionaire

ESS-Questionaire

How likely are you to doze off (fall asleep) in the following situations? *

0 - No chance1 - Slight chance2 - Moderate chance3 - High chance

Sitting and reading

0 - No chance1 - Slight chance2 - Moderate chance3 - High chance

Watching television

0 - No chance1 - Slight chance2 - Moderate chance3 - High chance

Sitting inactive in a public space

0 - No chance1 - Slight chance2 - Moderate chance3 - High chance

Lying down to rest in the afternoon when circumstances permit

0 - No chance1 - Slight chance2 - Moderate chance3 - High chance

Sitting and talking to someone

0 - No chance1 - Slight chance2 - Moderate chance3 - High chance

Sitting quietly after a lunch without alcohol

0 - No chance1 - Slight chance2 - Moderate chance3 - High chance

As a passenger in a car for an hour without a break

0 - No chance1 - Slight chance2 - Moderate chance3 - High chance

In a car, while stopped for a few minutes in traffic

0 - No chance1 - Slight chance2 - Moderate chance3 - High chance

ESS Total

STOP BANG- Questionaire

Yes No

Do you snore loudly?

Yes No

Do you often feel tired?

Yes No

Has anyone observed you stop breathing or choking or gasping during sleep?

Yes No

Do you have or are you beign treated for high blood pressure?

Yes No

Is your body mass index more then 35kg/m²?

Yes No

Are you aged older then 50?

Yes No

Is your neck circumference (shirt size) more then 40cm?

Yes No

Is your gender male?

Yes No

STOP BANG total

Medical History

Please list any medical conditions including any allergies you currently have

Please list any medications your are currently taking

How many days a week do you consume alcohol *

What is your height (cm) *

What is your weight (kg) *

Have you ever collapsed suddenly, or your neck muscles felt too weak to hold up your head when you’ve laughed, become angry, surprised or shocked? (Cataplexy) *

YesNo

Do you suffer from sleep paralysis? *

YesNo

I have a commercial driver's liscence (trains, trucks, busses, planes and public transport vehicle eg. taxis & Uber) *

YesNo

I agree to the terms and conditions. *

I acknowledge and consent to the following:

The medical information and history I have provided prior to the procedure is complete and accurate.
I will return the portable device and all accessories/parts the following day, and understand that I may be charged for any damaged or missing equipment.
Discontinue use if any adverse reaction to electrode and/ or sensor attachments occurs.
Do not expose the device to liquids, e.g: the shower.
Do not expose the device to extreme heat, e.g: leave the device in your car on a hot day or in direct sunlight.
Do not drop or subject the device to any rough handling.

Non Refundable

All fees charged for booking the sleep study service is non-refundable. Please ensure you are certain with your choices prior to proceeding.

Sleep Study Results

We strongly encourage you to discuss your sleep study results with a medical practitioner before the initiation of any therapy.

How we collect, use and disclose your personal information

Arise Sleep Solutions is committed to the open and transparent management of the personal data you trust us with. In most cases, we will collect your personal information directly from you. However, where it would be unreasonable or impracticable to do so, we may obtain it from a third party, such as your referring physician. If you do not give us the information that we request, we may be unable to provide you with our products or services. Arise Sleep Solutions (we, us, our) collects your sensitive personal information, including health information, so that we can provide you with our products and services related to the treatment of your suspected or diagnosed sleep disorder, to interact with you, for the purpose of managing our business, as authorised or required by law, or as otherwise agreed by you. If you allow us to do so, we may also sometimes send you information about products or services that may be of interest to you. We may disclose your personal information, including health information, to third parties, such as your agents and representatives, your referring physicians, our related bodies, our third party service providers, our professional advisers, and government and regulatory bodies. We do not sell your personal information. By ticking this box, you agree to your sensitive personal information being handled in the ways described above.

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