Online Patient Form

Patient Name *

First Name Middle Name Last Name

Sleep Appliance Package

The price for the oral sleep appliance package is $3700. This alternative to CPAP package includes five parts: consultations (initial and explanation of orofacial findings), diagnostic records (information necessary to custom fit your oral sleep appliance), oral sleep appliance, up to 5(five) follow up visits, and modifications to the oral sleep appliance, as needed, for 1 year. Oral sleep appliance package DOES NOT include fees incurred for: lost appliances, broken appliances due to neglect or misuse, dental treatment (fillings/crowns), or TMJ dysfunction treatment.

Payment of Fees
Payment for treatment is due at the time of service. Medical and/or dental insurance may reimburse you for some or all of our services. It is YOUR responsibility to obtain any reimbursement. At the conclusion of treatment, a superbill that you can send to your insurance company will be provided as a courtesy.

Sincerely,
Darryl Azouz, DDS
Sacramento Natural Dentistry

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I understand and agree to the above-listed procedures and associated fees.

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(Your digital signature (full name) is as legally binding as a physical signature.)