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Home
Office
Meet the Doctors
Our Staff
Why Choose Us
Office & Financial Policies
Hours & Location
Patients
First Visit
Insurance
Patient Portal
Emergencies
Dental FAQs
Schedule A Visit
Treatment
Services
Before & After Pictures
Sleep Apnea
What is Sleep Apnea?
Sleep Apnea Treatment
Why Choose Us
Physician Referral Form
Patient Instructions
Blog
Contact
Fill out your information below please and we will contact you soon!
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Name
*
First
Last
Date of Birth
*
year? had to
Email
*
Phone
*
Do you have symptoms of Sleep Apnea?
Snoring
Gasping for air or stop breathing while sleeping
Daytime sleepiness
Morning headaches
Difficulty concentrating in daytime
Awakening with dry mouth or sore throat
Poor memory or moodiness
Chronic exhaustion
Do you have Sleep Apnea Risk Factors?
Family history of sleep apnea
Overweight
Are you male?
Over age 50
Heart problems
High blood pressure
Stroke or brain conditions
Use alcohol, sedatives, or smoke
Have you been diagnosed by a Physician with Obstructive Sleep Apnea?
*
Yes
No
Have you had a Sleep Study test in the last year?
*
Yes
No
Have you ever worn a CPAP device to treat Obstructive Sleep Apnea?
*
Yes
No
Have you had a dental exam in the last year?
*
Yes
No
Any Other Information you would like to tell us?
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