Please print and sign the Information For Consent For Dental Appliance of Snoring and/or Sleep Apnea and bring it to our office during your visit:

Oral sleep appliances used in this office are designed to assist breathing during sleep by moving the lower jaw forward, thereby keeping the tongue forward and opening the airway space in the throat which results in a reduction in snoring and obstructive sleep apnea. Oral sleep appliances substantially reduce snoring and sleep apnea in most cases, but there are no guarantees that this therapy will be successful for every individual. Several factors contribute to the snoring/apnea condition including nasal obstruction, narrow airway space in the throat and excess weight. Since each person is different and presents unique circumstances, oral appliances will not always reduce snoring and/or apnea for everyone.

Patients who have been diagnosed with sleep apnea should be monitored with routine visits to their physician or sleep disorders center. Moderate to severe obstructive sleep apnea is potentially a life threatening condition, and periodic monitoring is important. The oral appliance does not cure snoring or sleep apnea, but is designed to reduce snoring and apnea events while it is being worn. It is advised that the oral appliance be checked at least twice a year to ensure proper fit. The mouth should be examined also to ensure a healthy condition.

Most patients experience little, if any discomfort in wearing the sleep appliance, although it normally takes a few nights to adapt. You should inform this office immediately if you experience any discomfort in your teeth, gums, jaw, muscles or TMJ (jaw joint) from wearing the appliance.

Medical insurance will often reimburse patients for their payment of an appliance to treat sleep apnea. The cost of the appliance is usually not covered by dental insurance because it is made to treat a medical condition. Medical insurance does not cover the appliance for the treatment of snoring only. The name of a referring physician is usually required for reimbursement by medical insurance. Our business office will assist you in filing your claim to obtain reimbursement for your payment of the appliance.

I HAVE READ AND UNDERSTAND THE FOREGOING INFORMATION. I AM WILLING TO ACCEPT ANY AND ALL RISKS KNOWN AND UNKNOWN INVOLVED.