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Statement of Therapy
Today's date: November 8, 2024
Please select who will be participating...
Adult
Minor(s)
1 Minor
2 Minors
3 Minors
4 Minors
5 Minors
More Minors
6 Minors
7 Minors
8 Minors
9 Minors
10 Minors
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First
Participant's
Name
First Name
*
Last Name
*
First
Participant's
Age Acknowledgment
*
First
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
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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
*
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Clear
Close
Click to Sign
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Second
Participant's
Name
First Name
*
Last Name
*
Second
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
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1
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- Year -
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1915
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
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- Year -
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1915
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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1915
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
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1915
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
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1915
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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1918
1917
1916
1915
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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1918
1917
1916
1915
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
*
Check to receive information, news, and discounts by e-mail.
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
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- Year -
2024
2023
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2020
2019
2018
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2016
2015
2014
2013
2012
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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:
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