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Home Sleep Test - Clinic Order Form
Thank you for choosing Belun Ring home sleep test.
Please fill in this order form.
We will send you the device within 3 working days.
Report will be available within 3 working days from return of device.
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* Indicates required question
Email
*
Your email
Patient Information
This information will be shown in the test report.
Patient name
*
Your answer
Patient number
As an unique identifier of the patient. Up to 12 letters or numbers.
Your answer
Age
*
Your answer
Gender
*
Male
Female
Height
*
cm
Your answer
Weight
*
kg
Your answer
Test Start Date
The device will be sent to your clinic before this date. Leave this blank if you want us to contact you or the patient to fix the test date.
MM
/
DD
/
YYYY
Test End Date
The device will be sent back to Belun on this date.
MM
/
DD
/
YYYY
If the device will be delivered to the patient, please provide his/her contact information.
Patient address
Your answer
Patient phone number
Your answer
Clinic Information
Where we will send the device, report and invoice to.
Doctor's Name
*
Your answer
Company Name
*
For billing
Your answer
Contact Person
*
Who is handling this test order
Your answer
Phone Number
*
We will contact you by call and WhatsApp
Your answer
Address
Address of the clinic if you want the device to be delivered there.
Your answer
Email
*
We will send report and invoice by email.
Your answer
Please read our privacy policy at
https://shop.beluntech.com/policies/privacy-policy
. I consent to provide the personal data for the purpose of carrying out the home sleep test.
*
Yes
For any questions, please contact us at
Email:
cs@beluntech.com
Phone: +852-3706-5640
WhatsApp:
https://wa.me/85237065640
©2020-2021, Belun Technology Company Limited. All rights reserved.
A copy of your responses will be emailed to the address you provided.
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