Forms

This page houses all the essential forms needed for your program. From clinical testing to patient follow-up and delivery documentation, these forms help your team collect accurate data, maintain compliance, and deliver consistent care. Each form is available for download.

FORM
PURPOSE
DOWNLOAD
Airway & Sleep Evaluation
Standard intake questionnaire for initial sleep and airway screening.

Airway Evaluation Exam 

Clinical assessment form, including tongue size, Mallampati, and more.
Airway Evaluation Results
Documents Rhinometer/Pharyngometer test results and airway stability.
STOP-BANG Questionnaire
Screens for obstructive sleep apnea risk based on standardized scoring.
Patient OAT Follow-up Form
Tracks patient progress, side effects, and
sleep improvements post-delivery.
Proof Of Delivery for OAT
Documents receipt of the appliance and confirms proper fit.
Advance Beneficiary Notice of
Non-coverage (ABN)
Required form for Medicare patients acknowledging financial responsibility.
OAT Order Form
RX form for OAT treatment.
Physician Fax Transmittal Form
Cover sheet used when submitting the order form for physician review.
For questions or assistance, please contact your regional manager.