MD Rx for Oral appliance therapy

MD Rx for Oral appliance therapy
Patient Name*

First NameLast Name
Patient Email (we will send them a copy as well)
example@example.com
Patients Date of Birth*

MonthDayYear
Date
Patient presented to my office for sleep and/or breathing disorder consultation with the chief complaint of:

Excessive daytime sleepinessChronic FatigueSnoringBruxismMouth breathingHeadachesObserved apneaTrouble concentratingOther
I am requesting your permission to prescribe OAT (oral appliance therapy) to treat:

Snoring (R06.83)Obstructive sleep apnea (G 47.33)Maxillary hypoplasia (M26.02)Maxilla Retrognathia (M26.01)Mandible RetrognathiaMandible AsymmetryDentofacial functional abnormalitiesOther
Patient obstructive sleep apnea is

MildModerateSevere
AHI is:
Upload interpreted sleep test

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Please upload a copy of the Affidavit for intolerance or Non-compliance to CPAP

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Prescription is for :*

Sleep Apnea Appliance: E0486Oral Appliance therapy: 21299OtherOther
Doctor Name*

First NameLast Name
Doctors email
example@example.com
Dental office phone number*
Please enter a valid phone number.
Requesting doctors Signature*

Clear
Should be Empty: