Dental Sleep Medicine

Essential Forms

Informed Consent

Liability Release Forms

ESSENTIALS PACKAGE - $297
INFORMED CONSENT & LIABILITY RELEASE PACKAGE - $997

Listing of Included Documents

  • Affidavit for Intolerance to CPAP
  • Checklist for DSM
  • Cover Sheet for Documentation Request from Insurance Co for OSA Claim
  • Epworth Sleepiness Scale
  • GAP Request Letter for Insurance Company
  • General Release of Liability and Assumption of Risk for OSA
  • Informed Consent for OSA - General
  • Insurance Verificiation and Benefits Form
  • Letter to MD - Patient is Waiting on Tretment - OSA
  • Letter to MD - Patient Refuses Treatment - OSA
  • MAD Post Insertion Instructions
  • PCP Introduction Letter - Doing DSM
  • PCP/Specialist Contact Information Form
  • Proof of Delivery Oral Appliance
  • RX/Written Order
  • Sleep Terminology Definitions and Abbreviations
  • Use of Oral Appliance Questionnaire

Listing of Included Forms

  • Informed Consent - Patient Titration of Mandibular
  • Advancement Device - OSA
  • Informed Consent - Snoring - OSA
  • Informed Consent for CBCT Scan - Radiologist Refusal - OSA
  • Informed Consent for Cone Beam CT Scan- OSA
  • Informed Consent for Temporary Appliance - OSA
  • Informed Consent for Tongue Retaining Device - OSA
  • Informed Consent -General - OSA
  • Informed Refusal - CBCT - OSA
  • Informed Refusal - CPAP
  • Combination Therapy - OSA
  • Informed Refusal - Dental Sleep medicine Recall Appointment - OSA
  • Informed Refusal - Dental Work for OSA Treatment - OSA
  • Informed Refusal Implants for OSA
  • Informed Refusal - Mandibular Advancement Device - OSA
  • Informed Refusal - Patient Flouride - OSA
  • Informed Refusal - Positional Therapy - OSA
  • Informed Refusal - Referral for Final PSG - OSA
  • Informed Refusal - Referral for Sleep Physician Recall Appointment - OSA
  • Informed Refusal - Referral for Weight Loss - OSA
  • Informed Refusal - Referral to Dentist for Dental Work
  • Informed Refusal - Referral to Endodontist - OSA
  • Informed Refusal - Referral to General Dentist for Exam/Cleaning - OSA
  • Informed Refusal - Referral to Oral Surgeon - OSA
  • Informed Refusal - Referral to Oral Surgeon for Biopsy - OSA
  • Informed Refusal - Referral to Otolaryngologist - OSA
  • Informed Refusal - Referral to PCP for High Blood Pressure - OSA
  • Informed Refusal - Referral to Periodontist - OSA
  • Informed Refusal - Referral to Primary Care Physician - OSA
  • Informed Refusal - Referral to Sleep Physician - OSA
  • Release of Liability and Assumption of Risk - General - OSA
  • Release of Liability and Assumption of Risk - Lack of Teeth for MAD - OSA
  • Release of Liability and Assumption of Risk - Oral Hygiene - OSA
  • Release of Liability and Assumption of Risk - Orthodontic Treatment - OSA
  • Release of Liability and Assumption of Risk - Patient Medication - OSA
  • Release of Liability and Assumption of Risk - Patient with Denture - OSA
  • Release of Liability and Assumption of Risk - TMD
  • Release of Liabilty and Assumption of Risk - Periodontal Disease - OSA
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