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Statement of Therapy

Today's date: December 3, 2024

First Participant's Name

First Name*

Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
I prefer to use an oral appliance treatment over CPAP treatment.*
No
Yes
I am CPAP intolerant for the following reasons: *
Mask Leaks
An Inability to get the Mask to Fit Properly
Discomfort Caused by the Straps and Headgear
Disturbed or Interrupted Sleep Caused by the Presence of the Device
Noise From the Device Disturbing Sleep or Bed/Partner's Sleep
CPAP Restricted Movements During Sleep
Latex Allergy
Claustrophobic Associations
An Unconscious Need to Remove the CPAP Apparatus at Night
I Would Like to Use Oral Appliance Therapy in Conjunction with CPAP Therapy to Reduce the CPAP Pressure.
Other

If other, please explain:
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
I prefer to use an oral appliance treatment over CPAP treatment.*
No
Yes
I am CPAP intolerant for the following reasons: *
Mask Leaks
An Inability to get the Mask to Fit Properly
Discomfort Caused by the Straps and Headgear
Disturbed or Interrupted Sleep Caused by the Presence of the Device
Noise From the Device Disturbing Sleep or Bed/Partner's Sleep
CPAP Restricted Movements During Sleep
Latex Allergy
Claustrophobic Associations
An Unconscious Need to Remove the CPAP Apparatus at Night
I Would Like to Use Oral Appliance Therapy in Conjunction with CPAP Therapy to Reduce the CPAP Pressure.
Other

If other, please explain:
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
I prefer to use an oral appliance treatment over CPAP treatment.*
No
Yes
I am CPAP intolerant for the following reasons: *
Mask Leaks
An Inability to get the Mask to Fit Properly
Discomfort Caused by the Straps and Headgear
Disturbed or Interrupted Sleep Caused by the Presence of the Device
Noise From the Device Disturbing Sleep or Bed/Partner's Sleep
CPAP Restricted Movements During Sleep
Latex Allergy
Claustrophobic Associations
An Unconscious Need to Remove the CPAP Apparatus at Night
I Would Like to Use Oral Appliance Therapy in Conjunction with CPAP Therapy to Reduce the CPAP Pressure.
Other

If other, please explain:
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
I prefer to use an oral appliance treatment over CPAP treatment.*
No
Yes
I am CPAP intolerant for the following reasons: *
Mask Leaks
An Inability to get the Mask to Fit Properly
Discomfort Caused by the Straps and Headgear
Disturbed or Interrupted Sleep Caused by the Presence of the Device
Noise From the Device Disturbing Sleep or Bed/Partner's Sleep
CPAP Restricted Movements During Sleep
Latex Allergy
Claustrophobic Associations
An Unconscious Need to Remove the CPAP Apparatus at Night
I Would Like to Use Oral Appliance Therapy in Conjunction with CPAP Therapy to Reduce the CPAP Pressure.
Other

If other, please explain:
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
I prefer to use an oral appliance treatment over CPAP treatment.*
No
Yes
I am CPAP intolerant for the following reasons: *
Mask Leaks
An Inability to get the Mask to Fit Properly
Discomfort Caused by the Straps and Headgear
Disturbed or Interrupted Sleep Caused by the Presence of the Device
Noise From the Device Disturbing Sleep or Bed/Partner's Sleep
CPAP Restricted Movements During Sleep
Latex Allergy
Claustrophobic Associations
An Unconscious Need to Remove the CPAP Apparatus at Night
I Would Like to Use Oral Appliance Therapy in Conjunction with CPAP Therapy to Reduce the CPAP Pressure.
Other

If other, please explain:
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
I prefer to use an oral appliance treatment over CPAP treatment.*
No
Yes
I am CPAP intolerant for the following reasons: *
Mask Leaks
An Inability to get the Mask to Fit Properly
Discomfort Caused by the Straps and Headgear
Disturbed or Interrupted Sleep Caused by the Presence of the Device
Noise From the Device Disturbing Sleep or Bed/Partner's Sleep
CPAP Restricted Movements During Sleep
Latex Allergy
Claustrophobic Associations
An Unconscious Need to Remove the CPAP Apparatus at Night
I Would Like to Use Oral Appliance Therapy in Conjunction with CPAP Therapy to Reduce the CPAP Pressure.
Other

If other, please explain:
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
I prefer to use an oral appliance treatment over CPAP treatment.*
No
Yes
I am CPAP intolerant for the following reasons: *
Mask Leaks
An Inability to get the Mask to Fit Properly
Discomfort Caused by the Straps and Headgear
Disturbed or Interrupted Sleep Caused by the Presence of the Device
Noise From the Device Disturbing Sleep or Bed/Partner's Sleep
CPAP Restricted Movements During Sleep
Latex Allergy
Claustrophobic Associations
An Unconscious Need to Remove the CPAP Apparatus at Night
I Would Like to Use Oral Appliance Therapy in Conjunction with CPAP Therapy to Reduce the CPAP Pressure.
Other

If other, please explain:
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
I prefer to use an oral appliance treatment over CPAP treatment.*
No
Yes
I am CPAP intolerant for the following reasons: *
Mask Leaks
An Inability to get the Mask to Fit Properly
Discomfort Caused by the Straps and Headgear
Disturbed or Interrupted Sleep Caused by the Presence of the Device
Noise From the Device Disturbing Sleep or Bed/Partner's Sleep
CPAP Restricted Movements During Sleep
Latex Allergy
Claustrophobic Associations
An Unconscious Need to Remove the CPAP Apparatus at Night
I Would Like to Use Oral Appliance Therapy in Conjunction with CPAP Therapy to Reduce the CPAP Pressure.
Other

If other, please explain:
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
I prefer to use an oral appliance treatment over CPAP treatment.*
No
Yes
I am CPAP intolerant for the following reasons: *
Mask Leaks
An Inability to get the Mask to Fit Properly
Discomfort Caused by the Straps and Headgear
Disturbed or Interrupted Sleep Caused by the Presence of the Device
Noise From the Device Disturbing Sleep or Bed/Partner's Sleep
CPAP Restricted Movements During Sleep
Latex Allergy
Claustrophobic Associations
An Unconscious Need to Remove the CPAP Apparatus at Night
I Would Like to Use Oral Appliance Therapy in Conjunction with CPAP Therapy to Reduce the CPAP Pressure.
Other

If other, please explain:
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
I prefer to use an oral appliance treatment over CPAP treatment.*
No
Yes
I am CPAP intolerant for the following reasons: *
Mask Leaks
An Inability to get the Mask to Fit Properly
Discomfort Caused by the Straps and Headgear
Disturbed or Interrupted Sleep Caused by the Presence of the Device
Noise From the Device Disturbing Sleep or Bed/Partner's Sleep
CPAP Restricted Movements During Sleep
Latex Allergy
Claustrophobic Associations
An Unconscious Need to Remove the CPAP Apparatus at Night
I Would Like to Use Oral Appliance Therapy in Conjunction with CPAP Therapy to Reduce the CPAP Pressure.
Other

If other, please explain:
Parent or Guardian's Email Address

Email*

Confirm Email*
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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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
I prefer to use an oral appliance treatment over CPAP treatment.*
No
Yes
I am CPAP intolerant for the following reasons: *
Mask Leaks
An Inability to get the Mask to Fit Properly
Discomfort Caused by the Straps and Headgear
Disturbed or Interrupted Sleep Caused by the Presence of the Device
Noise From the Device Disturbing Sleep or Bed/Partner's Sleep
CPAP Restricted Movements During Sleep
Latex Allergy
Claustrophobic Associations
An Unconscious Need to Remove the CPAP Apparatus at Night
I Would Like to Use Oral Appliance Therapy in Conjunction with CPAP Therapy to Reduce the CPAP Pressure.
Other

If other, please explain:
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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