PEDIATRIC REFERRAL FORM FOR SLEEP-DISORDERED BREATHING EVALUATION

Dear Physician,

I am referring to you the following patient for evaluation of Sleep-Disordered Breathing due to the reasons listed below. The patient’s parent/guardian initially contacted us in regard to fabricating them an oral appliance for potential OSA. As the patient is too young for this treatment modality at this time, they would benefit from an evaluation with you to discuss other potential treatment options further. If oral surgery or orthodontic treatment is elected, please let us know as we are happy to help facilitate the referral of the patient to one of our trusted colleagues that may be in network with their dental insurance. If appropriate at a later age, we will fabricate a custom oral appliance to help them breathe better at night. You will then be asked to order a titration sleep study to confirm efficacy. The sleep technician will titrate the appliance to full treatment or add a small amount of CPAP if indicated or tolerated.

Patient Name

First NameLast Name

Parent / Guardian Name:

First NameLast Name

Parent / Guardian Phone Number

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Address

Street Address

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Reason for Referral: The patient’s parents/guardians report concern regarding their child’s breathing during sleep and a potential link to the following known conditions.Parent/Guardian-reported conditions for patient:

Patient Date of Birth

Date