RX Oral Appliance Therapy: Obstructive Sleep Apnea

RX for Oral Appliance Therapy for Obstructive Sleep Apnea

 

Physician:____________________________________ Telephone:_____________

Office Address:______________________________________________________

 

Patient Name:_______________________________________________________

Patient Address:_____________________________________________________

Patient Telephone: H):_____________________(Cell):______________________

 

Prescription to be filled by:

Leland C. Wilhoite, D.D.S.

www.wilhoitefamilydental.com

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: _________________________________________

Date:_________________

 

*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 info@wilhoitefamilydental.com