Rx for Oral Appliance Therapy
For Medically Diagnosed Obstructive Sleep Apnea
Patient Name:
DOB:
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AHI/ RDI:
The patient referred has been evaluated by the physician listed below and has been diagnosed with the following:
Primary Snoring (R06.83)
Obstructive Sleep Apnea (C47.33)
Other
This patient
Is intolerant to positive airway pressure (PAP) treatment.
Is not a candidate for positive airway pressure (PAP) treatment
Has decided, after all options have been discussed, they would like to proceed with oral appliance therapy as their initial treatment.
Requires combination treatment of an oral appliance and CPAP therapy.
Other:
Physician Signature
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Submit
Should be Empty: