Get the free Oral Appliance Referral Form - Louisville Dental Sleep Medicine

LOUISVILLE DENTAL SLEEP MEDICINE JOHN M MacGillis DMD Diplomat, American Board of Dental Sleep Medicine 2902 Taylorsville Road, Louisville KY 40205 5024587476 ORAL APPLIANCE ORDER FORM FAX TO: (502)

How to fill out oral appliance referral form

How to fill out an oral appliance referral form:

1. Start by reviewing the form thoroughly to understand the information and sections required.
2. Fill out the patient's personal details accurately, including their full name, date of birth, address, and contact information.
3. Indicate the reason for the referral, specifying that it is for an oral appliance.
4. Provide information about the referring healthcare professional, including their name, contact details, and any relevant credentials.
5. Include the patient's medical history, highlighting any relevant conditions or previous treatments.
6. Specify the type of oral appliance needed, if known, or leave it blank if the specific type will be determined later.
7. Attach any supporting documents, such as dental records, previous diagnostic reports, or relevant X-rays.
8. Sign and date the form, verifying that the information provided is accurate to the best of your knowledge.

Who needs an oral appliance referral form:

1. Patients who have been diagnosed with certain conditions that may benefit from using an oral appliance, such as sleep apnea or temporomandibular joint disorder (TMJ).
2. Those who have symptoms such as loud snoring, breathing difficulties during sleep, or jaw pain, which may indicate a need for an oral appliance.
3. Individuals who have been previously recommended or prescribed an oral appliance by a healthcare professional.

Note: It is essential to consult with a qualified healthcare provider or dentist to determine whether an oral appliance is suitable for an individual's specific needs and conditions.

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