Materials >> Pre-screener

 

Download Word template
Or, use the order form to have prints delivered

Size:  8.5 x 11 (letter-sized, 2-sided or 2 pages)

Front side:  Help patients self-identify insomnia, gives a place to offer contact information for proactive follow-up, and creates a way for patients to prompt discussion of insomnia with their doctors. It could be…

  • provided with a doctor’s visit reminder for an upcoming appointment

  • included pre-visit paperwork when a person enters the waiting room

  • given to a patient by a nurse or MA during vitals + wait for doctor

Back side: Provides PCPs a quick reminder of referral process and eligibility criteria.

“For office use only” section can be completed and sent to COZI team partners (via fax, secure email, or other method) to document referral and medication preference for that particular patient.

Customization:
Local logo
Referral instructions agreed upon with COZI team partners