Forms & Surveys
Where Service Comes First...
A CHAP certified company
Are you suffering from Obstructive Sleep Apnea?
Are you suffering from Breathlessness?
Take our screening surveys below and find out.
The Berlin Questionnaire: For Obstructive Sleep Apnea (OSA) take the simple Berlin Questionnaire and present it to your physician.

Epworth Sleepiness Scale - For OSA, less accurate than the Berlin Questionnaire.

Do you suffer from COPD?  Find out by taking this simple  COPD Questionnaire and presenting it to your physician.

Click here to download AMES Referral Form.  This form is to be used for patient referrals

Track Compliance for your clients

AMES Referral Form

Information marked with asterisk below is required.  Additionally, a copy of the signed prescription order must be faxed to our office at (623) 266-7254. For questions, please call (623) 266-7255. 

Thank you for doing business with AMES!
Patient Information
First Name: *
Last Name: *
Address Street 1: *
Address Street 2:
City: *
Zip Code: * (5 digits)
State: *
DOB: *
Weight: *
Height: *
Gender: *
Insurance Information
Primary Insurance: *
Secondary Insurance: *
Contact Information
Daytime Phone: *
Cell Phone: *
Email:
Prescription Information
Prescription Details *
M.D./D.O. Name: *

By clicking the box below, I authorize the use of this document as a legal prescription, and I certify that the above prescribed equipment is medically necessary and reasonable, and is not being prescribed for convenience. I will maintain a copy of this order or prescription in my medical records and make it available to Medicare, their authorized agents or other insurer, if required.


COPD QuestionnaireChronic Obstructive Lung Disease
Tel: (623) 266-7255 or (928) 771-9228
Fax: (623) 266-7254 or (928) 771-0376
Content copyright . AMES. All rights reserved.
Web Hosting Companies