Oral Appliance Therapy Referral Form

Patient Information
Please evaluate:
Name*
First Last
for treatment with oral appliances due to the following:
- CPAP Intolerance
- Primary Snoring
- Mild or Moderate OSA
- Adjunct to CPAP or Surgery
- Inadequate Surgical Results
Comments
Polysomnogram
The patient has a polysomnogram available:
- Yes
- No
If available, please fax polysomnogram report to: (906) 786-0548.
Physician Information
Physician Name
First Last
Physician Phone
NPI Number
Please note that no dental services will be rendered and that the patient will be referred back to their dentist for treatment. You will be continually updated on the progress of oral appliance therapy.
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Patient Information