Your co-operaetion in completing this questionnaire is essential to providing you with the highest standard of dental care. Please answer the questions accurately as you can. All information is strictly confidential and will remain with this office. We understand the importance of protecting your personal information.
PLEASE BE PATIENT, IT IS DETAILED
QUESTIONS WITH * MUST BE ANSWERED
I release you from all legal responsibility that may arise from this authorization.
If you answered yes to 2 or more questions, it is very likley that you are at significant risk for obstructive sleep apnea.
If you answered yes to 3 or more questions, it is very likley that you have moderate to severe obstructive sleep apnea.
Credit Card on file will be required at the first appointment. Unless the patient will have a credit card with parents approval.