Dr. Nancy Addy, DDS
Dr. Jarrett Grosdidier, DDS
Dr. Josh Matthews, DDS
Date of Birth
The patient referred with this form has been evaluated by the above physician and has been diagnosed to have:
Mild Obstructive Sleep Apnea
Moderate Obstructive Sleep Apnea
Severe Obstructive Sleep Apnea
The patient is:
Not a candidate for CPAP therapy
As a physician, I deem this therapy to be medically necessary. Patient is being referred for:
Oral Appliance Therapy
Mouth Closing Device
Home Sleep Test (HST)
Date of sleep study
Please attach sleep study results
Copies of sleep study results are required for appropriate care. If you do not have the sleep study at the time of submitting this referral, you may return to our website later and separately submit the sleep study on another form.
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Obstructive Sleep Apnea is a medical condition that tends to become more severe with time and requires periodic re-evaluation by a qualified physician.