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Sacramento Natural Dentistry


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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):
Mask leaks
Mask uncomfortable/Device uncomfortable
Unable to sleep comfortably
Noise disturbs my sleep and/or bed partners sleep
Restricts movement during sleep
Does not seem to be effective
Straps/headgear cause discomfort
Pressure on the upper lip cause tooth related problems
Other:

* 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. Azouz.
*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)