RX Oral Appliance Therapy: Obstructive Sleep Apnea
RX for Oral Appliance Therapy for Obstructive Sleep Apnea
Patient Telephone: H):_____________________(Cell):______________________
Prescription to be filled by:
Leland C. Wilhoite, D.D.S.
2623 W. Jackson St.
Muncie IN 47303
Phone: 765.289.6373 FAX: 765.289.6375
The patient referred with this form has been evaluated by the above physician and has been diagnosed,
using acceptable medical criteria, to have:
? Obstructive sleep apnea or Severity______________________
? Simple Snoring.
This patient is :
? Intolerant of CPAP therapy
? Is not a candidate for CPAP therapy
Explanation (if necessary): ____________________________________________________
The patient is being sent for OA therapy with:
? The appliance chosen by the dentist and the patient as most suitable
? A__________________________________appliance (specific name)
Signature of Referring Physician: _________________________________________
*As a physician, I deem this therapy to be medically necessary.
Obstructive Sleep Apnea is a medical condition that tends to become more severe with time, and
requires periodic re-evaluation by a qualified physician.
Oral Appliance Therapy is less effective in controlling this disease than CPAP, and patients referred
for this therapy may need to explore additional options of treatment if the appliance alone is deemed
to provide suboptimal management of the sleep apnea.
Copies of diagnostic and PAP titration PSG with full report are required for appropriate care and
to obtain medical insurance coverage.
Original Prescription should be mailed or delivered to email@example.com