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CPAP Consent

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leaf icon CPAP Intolerance Consent

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  • 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.
  • 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.

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