affidavit for intolerance to CPAP

For Patient:
First Name:      Last Name: 

I have attempted to use the 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) (Please check all that apply):

       
       
       
       
       
       
       
       
       
       
       
       


Because of my intolerance/inability to use the CPAP, I wish to have an alternative method of treatment.
That form of therapy is oral appliance therapy (OAT).

Patient/Responsible Party: