Affidavit for Intolerance or Non Compliance to CPAP

Type a question

	Yes	No
I have discussed CPAP with my physician and am refusing CPAP at this time.
I am not able to try and tolerate CPAP treatment at this time.
I prefer oral appliance VS CPAP if I am diagnosed with sleep apnea.
I have attempted to use CPAP (Continuous Positive Air Pressure) to manage my sleep related breathing disorder.
I prefer to use the oral appliance in combination with my CPAP to lower the pressure setting on my CPAP.

PLEASE SEE FOLLOWING REASONS FOR INTOLERANCE OR NON-COMPLIANCE
Type a question

I cannot tolerate anything on face due to claustrophobia when sleeping.An inability to get the mask to fit properlyDiscomfort caused by the straps and headgearDisturbed or interrupted sleep caused by the presence of the device and most likely wouldn't be able to keep it on.Noise from the device disturbing sleep or bed partner's sleepCPAP restricted movements during sleepCPAP does not seem to be effectivePressure on the upper lip causes tooth related problemsCpap caused distended stomach, burping and/or irritated IBS symptoms.CPAP has caused lack of intimacy in my relationship.Difficulties sleeping after removing/replacing cpap after having to go to the bathroomLatex AllergyNo electricity for usage of CPAP
I have attempted the following due to my sleep apnea/snoring:

Nasal StripsNose conesPositional Therapy (Changing positions while sleeping)Dieting/Weight loss
Because of my intolerance and/or inability to use or try the CPAP or because I am refusing CPAP, I wish to have my OSA treated by Oral Appliance Therapy utilizing a custom fitted Mandibular Advancement Device.

Clear
Date

MonthDayYear
Date
East Hampton

87 Newtown Lane
East Hampton, NY 11937
(631) 856-1835
Riverhead

235 Osborn Avenue
Riverhead, NY 11901
(631) 658-5168
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Affidavit for Intolerance or Non-Compliance to CPAP