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INFORMED CONSENT FOR ORAL APPLIANCE THERAPY FOR THE TREATMENT OF SLEEP DISORDERED BREATHING

You have been diagnosed by your physician, OR are interested in being diagnosed, 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 that may result in excessive daytime sleepiness, irregular heartbeat, high blood pressure, heart attack or stroke.

Oral appliance therapy for snoring/obstructive sleep apnea assists breathing during sleep by keeping the tongue and jaw in a forward position during sleep. 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 that influence 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. If you are medically diagnosed as having sleep apnea, a follow-up sleep study to objectively assure effective treatment should be obtained from your physician.

Published studies show that short-term side effects of oral appliance use may include excessive salivation, difficulty swallowing with the appliance in place, sore jaws, sore teeth, jaw joint pain, dry mouth, gum pain, loosening of teeth and short-term bite changes. There are also reports of the dislodgment of ill-fitting dental restorations. Most of those 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 that result from tooth movement and/or jaw joint repositioning. These complications may or may not be fully reversible once appliance therapy is discontinued. If not, restorative treatment or orthodontic intervention may be suggested in certain cases for which you will be responsible.

Follow-up visits with the provider of your oral appliance are mandatory to ensure proper fit and to allow an examination of your mouth to assure a healthy condition. If unusual symptoms or discomfort occur 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.

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 this provider's office. Failure to treat sleep-disordered breathing may increase the likelihood of significant medical complications.

I understand that I will be solely responsible for any costs not covered by my insurance provider, and that all full or partial payments are final and will not be refunded.

I have received, read and understand the conditions and information in this letter.

I have had the opportunity to discuss the foregoing conditions and the information concerning the oral appliance. Furthermore, I give my permission for my diagnostic and treatment records to be used by Build a Smile in conjunction with my treatment.  I also accept financial responsibility for this therapy. With all of the foregoing in mind, I authorize treatment and confirm that I have received a copy of this consent form.

Date: June 14, 2021

First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Signature*
Second Patient's Name

First Name*

Middle Name

Last Name*
Second Patient's Date of Birth*
Third Patient's Name

First Name*

Middle Name

Last Name*
Third Patient's Date of Birth*
Fourth Patient's Name

First Name*

Middle Name

Last Name*
Fourth Patient's Date of Birth*
Fifth Patient's Name

First Name*

Middle Name

Last Name*
Fifth Patient's Date of Birth*
Sixth Patient's Name

First Name*

Middle Name

Last Name*
Sixth Patient's Date of Birth*
Seventh Patient's Name

First Name*

Middle Name

Last Name*
Seventh Patient's Date of Birth*
Eighth Patient's Name

First Name*

Middle Name

Last Name*
Eighth Patient's Date of Birth*
Ninth Patient's Name

First Name*

Middle Name

Last Name*
Ninth Patient's Date of Birth*
Tenth Patient's Name

First Name*

Middle Name

Last Name*
Tenth Patient's Date of Birth*
Patient's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Physician List

Primary Care Physician: (Name, City, Phone Number)

Sleep Physician: (Name, City, Phone Number)
Are you under the care of a specialist? (cardiologist, internist, etc.)*
No
Yes

If Yes, Please Provide Name, City, Phone Number of Physician
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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