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CPAP Consent

  • Ask The Doctor

 CPAP Intolerance Consent

  • Affidavit For Intolerance to CPAP


  • I have attempted to use nasal CPAP to manage my sleep related breathing disorder (apnea) and find it intolerable to use on a regular basis for the following reason(s):

  • Because of my intolerance/inability to use CPAP I wish to have an alternative method of treatment. That form of therapy is an Oral Airway Dilator appliance, as prescribed to me by Dr. Wall.
  • Date Format: MM slash DD slash YYYY

After submitting, feel free to return to the Patient Forms page. Please note, there are multiple forms for each section.

Schedule Your Appointment with the Holistic Dentist

Every service we offer is aimed at improving your overall health. We offer several procedures that eliminate the need for surgical incisions, reducing your discomfort, downtime, and the need for multiple visits. Call our office to schedule your consultation today.