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Ryan G. Wetzler Psy. D. C. BSM ABPP Sleep and Health Psychologist 3430 Newburg Rd. Louisville Kentucky 40218 Phone Marcia 502 454 0755 ext 137 Fax 502 479 1231 referral form - consultation request Patient s Name DOB Patient Contact Number Primary Insurance Evaluate and Treat for Sleep Disorder insomnia parasomnia hypersomnia circadian rhythm sleep disorder Headaches migraine tension Pre-surgical psychological evaluation and diagnostic Please specify surgical procedure impression Other...
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