CPAP Intolerance I Non-Compliance Affidavit

Please correct the errors described below.

Patient's Name

Date

It has been recommended and/or I have attempted to use CPAP (Continuous Positive Air Pressure) to manage my diagnosed Obstructive Sleep Apnea condition. I find CPAP intolerable to use on a regular basis due to the following reason(s):

The Mask Leaks

OI am unable to sleep with the CPAP mask and equipment in place

I unconsciously remove the CPAP at night

The noise from the device disturbs my sleep

CPAP does not seem to be effective in reducing/eliminating my symptoms

I have tried multiple masks and none are comfortable enough to use

I develop sin us/ear/throat infections

I am claustrophobic

My job/lifestyle prevent nightly use (Army, Reserves, Truck Driver)

Other

Because of my intolerance and inability for CPAP to effectively treat my condition, I wish to attempt an alternative therapy. As per the 2006 practice parameters from the American Academy of Sleep Medicine I wish to utilize an oral airway dilator appliance to treat my obstructive sleep apnea.

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Patient Signature

Date

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