Santa Cruz Location | Sleep Apnea Treatment

Contact Information

Hours of Operation

Monday through Friday. 9-5pm

Offering Alternatives To CPAP In Santa Cruz & Surrounding Areas

East Bay: Fremont, Milpitas, Walnut Creek, Pleasanton
South Bay: San Jose, Los Gatos, Campbell, Morgan Hill, Gilroy, Salinas
Peninsula: Mountain View, Redwood City, Menlo Park, Cupertino, Saratoga, Santa Clara

Requesting Physician's Name:

Requesting Physician's email:

DOB (Date of Birth):

Patient's Contact Number:

Patient's Diagnostic Sleep Study Results (without CPAP or OA):

Date of Study:

Respiratory Disturbance Index (RDI):

Apnea Hyponea Index (AHI):

Lowest O2 Saturation (SpO2):

Statement of Medical Necessity

I am referring the above patient to Dr. Srujal H Shah, DDS INC because I believe it is Medically Necessary for him/her to be
fitted for a custom fitted oral appliance, E0486.

Physician's Signature:

Date:

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Treating Sleep Apnea In Santa Cruz

Contact Information

Hours of Operation

Offering Alternatives To CPAP In Santa Cruz & Surrounding Areas

Treating Sleep Apnea In Santa Cruz

Oral Appliance Therapy Rx & Medical Necessity Form for Medically Diagnosed Obstructive Sleep Apnea