NEW BERLIN DENTAL

Name

Patients First NamePatients Last Name
Date of Birth

MonthDayYear
Date
Patient Phone Number
Please enter a valid phone number.
The patient referred with this form has been evaluated by the above physician and has been diagnosed to have:

Mild Obstructive Sleep ApneaModerate Obstructive Sleep ApneaSevere Obstructive Sleep ApneaSimple Snoring
The patient is:

CPAP intolerantNot a candidate for CPAP therapyOther
As a physician, I deem this therapy to be medically necessary. Patient is being referred for:

Oral Sleep Appliance Therapy
Date of sleep study

MonthDayYear
Date
Please attach sleep study results

Cancelof
Copies of sleep study results are required for appropriate care. If you do not have the sleep study at the time of submitting this referral, you may return to our website later and separately submit the sleep study on another form.
Physician Signature

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Date

MonthDayYear
Date
By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature. Obstructive Sleep Apnea is a medical condition that tends to become more severe with time and requires periodic re-evaluation by a qualified physician.
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