Forms & Surveys
Do you feel sleepy during daytime?

Fill out the questionnaire 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, take the survey and present it to your physician. 

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

Some of the links on this page require a plug-in to view them. Links to the plug-ins are available below.

Click Here to Download Adobe Acrobat Reader Adobe Acrobat (PDF)

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: *
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.

Tel: (623) 266-7255 or (928) 771-9228
Fax: (623) 266-7254 or (928) 771-0376

Disclaimer: This information is intended for general education purposes only and should not be
relied upon as a substitute for professional and/or medical advice. Arizona Medical Equipment & Supply LLC accepts no liability for the content on this website or for the consequences of any action taken on the 
basis of the information provided. 

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