Online Patient Form

Patient Name *

First Name Middle Name Last Name

Affidavit For Intolerance To Cpap

I have attempted to use nasal CPAP to manage my sleep related breathing disorder (apnea) and find it intolerable to use on a regular basis for the following reason(s):

Mask leaks Mask uncomfortable/Device uncomfortable Unable to sleep comfortably Noise disturbs my sleep and/or bed partners sleep Restricts movement during sleep Does not seem to be effective Straps/headgear cause discomfort Pressure on the upper lip cause tooth related problems

*

Because of my intolerance/inability to use CPAP I wish to have an alternative method of treatment. That form of therapy is an Oral Airway Dilator appliance, as prescribed to me by Dr. Azouz.

Signature *

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Date *

Date

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