Fillable Intake Form

Intake Form
Name*

First NameLast Name
Preferred Name
What would you like to be called?
Home Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Sleep Physician
Sleep Physician's Phone Number
Please enter a valid phone number.
Primary Care Physician
Primary Care Physician's Phone Number
Please enter a valid phone number.
Dentist
Dentist's Phone Number
Please enter a valid phone number.
Other Care Providers
Any other care providers you would like to mention?
Other Care Provider's Phone Number
Please enter a valid phone number.

Patient Authorization, Assignment of Benefits & Financial Agreement
In return for the services provided by Diamond Dental Sleep Solutions, (the “Practice”) I understand that all applicable copayments and deductibles are due at the time of service. I will pay my account at the time service is rendered to me or will make financial arrangements satisfactory to the Practice for payment. I agree to be financially responsible and make full payment for all charges not covered by my insurance company, including in instances where my coverages lapses or if I fail to give the requisite insurance information to the office. I authorize my insurance benefits to be paid directly to the Practice for services rendered. I authorize representatives of the Practice to release pertinent information to my insurance company when requested or to facilitate payment of a claim. I assign to the Practice any benefits of any type under any policy of insurance that insures me or any other party liable to me. In the event I receive payment from the insurance company for services rendered by the Practice and fail to remit such payment to the Practice immediately then I acknowledge and agree that I will be responsible for any fees, including legal fees associated with Dental Sleep Solutions’ collection efforts from me. If my account is sent to an attorney for collection, I agree to pay collection expenses and reasonable attorney’s fees as established by the court and not by a jury in any court action. If my account is delinquent, I may be charged interest at the legal rate. I agree to be primarily responsible for the payment of the Practice’s bill. I read and agree to all of the above.*

Clear
Date*

MonthDayYear
Date

Today's Date:

MonthDayYear
Date
Date of Birth:

MonthDayYear
Date
Social Security Number:
Name:
Address

Street Address

CityState / Province

Postal / Zip Code
I, the undersigned, do hereby grant permission for Dr. Asher Diamond to:
obtain from and release to   name of person or institution   the following information from the patient's clinical records:
all medical records   other   limited records   .

I understand that this information will be used for the purposes of:   Providing information to allow care to be provided to the patient   supporting the payment of an insurance claim
Other   other

This authorization will be valid for a period of twelve months unless otherwise specified.
Signature*

Clear
Date

MonthDayYear
Date
Relationship to patient:

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. The most common reason why we use or disclose your health information is for treatment, payment, or health care operations. Examples include setting up appointments for you, examining your teeth, prescribing medications, referring you to another doctor, or getting copies of your health information from another professional, insurance, etc. By signing below, you acknowledge that you have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how your health information may be used and disclosed by Diamond Dental Sleep Solutions and how you may obtain access to and control this information.

The full notice is available upon request.

By checking this box, I expressly permit Diamond Dental Sleep Solutions to disclose my protected health information for the purposes of appointment / test / procedure reminder and follow-up by leaving such information in the form of a message on the following recorded media:
- Text messaging
- Home answering machine
- Cell phone voicemail
- Email
- Other (specify): ___________________________________________
I agree
Signature

Clear
Date

MonthDayYear
Date
You may Refuse to sign this acknowledgement. If you refuse to sign, please indicate the reason:
Reason for Refusal to sign:

Informed Consent for the Treatment of Sleep Disordered Breathing
You have been diagnosed by your physician as requiring treatment for sleep-disordered breathing (snoring and/or obstructive sleep apnea). This condition may pose serious health risks since it disrupts normal sleep patterns and can reduce normal blood oxygen levels, which in turn, may result in the following: excessive daytime sleepiness, irregular heartbeats, high blood pressure, heart attack, or stroke. All individuals are advised to consult with a physician for accurate diagnosis of their condition before treatment can be started.

What is Oral Appliance Therapy?
Oral appliance therapy for snoring/obstructive sleep apnea attempts to assist breathing during sleep by mechanically keeping the tongue and jaw in a forward position, thereby opening the airway space. Oral appliance therapy has effectively treated many patients. However, there are no guarantees that it will be effective for you, since everyone is different and there are many factors influencing the upper airway during sleep. It is important to recognize that even when the therapy is effective, there may be a period of time before the appliance functions maximally. During this time you may still experience the symptoms related to your sleep disordered breathing. A post adjustment polysomnogram (sleep study) is necessary to objectively assure effective treatment. This must be obtained from your physician. Oral appliance therapy does not cure snoring or obstructive sleep apnea. The device must be worn nightly for the duration of the disease, often for life.

Side Effects and Complications of Oral Appliance Therapy
Studies show that short-term side effects of oral appliance use may include excessive salivation, difficulty swallowing with appliance in place, sore jaws, sore teeth, jaw joint pain, dry mouth, gum pain, loosening of teeth and short-term bite changes (how the upper and lower teeth come together). There are also reports of dislodgement of ill-fitting dental restorations. Most of these side-effects are minor and resolve quickly on their own or with minor adjustment of the appliance. Long-term complications include bite changes that may be permanent, resulting from tooth movement or jaw joint repositioning. Additionally, using an Oral Appliance, specifically a mandibular advancement device (MAD) to treat obstructive sleep apnea may worsen the symptoms of TMJ disease and associated pain could get worse and, in some instances, become permanent causing severe pain and disability. These complications may or may not be fully reversible once appliance therapy is discontinued.

If not, restorative or orthodontic treatment may be required, for which you will be responsible.
Follow up visits with Dr. Diamond are mandatory to ensure proper fit and to allow an examination of your mouth to assure healthy condition. If unusual symptoms or discomfort occur that fall outside the scope of this consent, or if pain medication is required to control discomfort, it is recommended that you cease using the appliance until you are evaluated further.

Alternative Treatments for Sleep Disordered Breathing

Other accepted treatments for sleep-disordered breathing include behavioral modifications, positive airway pressure and various surgeries. It is your decision to have chosen oral appliance therapy to treat your sleep disordered breathing and you are aware that it may not be completely effective for you. It is your responsibility to report the occurrence of side effects and to address any questions to Dr. Diamond or the staff. Failure to treat sleep disordered breathing may increase the likelihood of significant medical complications.

If you understand the explanation of the proposed treatment, have asked Dr. Diamond or the staff any questions you may have about this form or treatment, please sign and date this form below. By your signature, you also acknowledge you have received a copy of this consent.
Signature*

Clear
Date

MonthDayYear
Date

Please upload a copy or take a photo of your MEDICAL insurance card

Browse Files

Cancelof
Take Photo
Should be Empty:

	Would never doze or sleep	Slight chance of dozing or sleeping	Moderate chance of dozing or sleeping	High chance of dozing or sleeping
Sitting and reading
Watching TV
Sitting inactive in a public place
Being a passenger in a motor vehicle for an hour or more
Lying down in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (no alcohol)
Stopped for a few minutes in traffic

Intake Form

History of Sleep Testing and Treatment

Dental History

Medical History

Patient Authorization, Assignment of Benefits & Financial Agreement

Epworth Sleepiness Scale

CPAP Intolerance Form

Informed Consent for the Treatment of Sleep Disordered Breathing