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00 Rem. Deduct. 00 Referred by Patient/Guardian Signature Date Jana Gyurina DDS LVIF 608. 833. 4466 OakParkDentalMadison.com 7617 Mineral Point Road Suite 120 Madison WI 53717 What are the chief complaints for which you are seeking treatment Please number the complaints with 1 being the MOST important. Yes No If yes Sleep Study Date Sleep Center Name/Location FOR OFFICE USE ONLY The evaluation confirmed a diagnosis of mild moderate severe CPAP Intolerance obstructive sleep apnea Height Weight...
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