Sleep Solutions of Columbus Pulmonary & Sleep Consultants, LLC

Powell Dental Group, LLC

M. Qadoom, M.D

Shelley D. Shults, RN, DDS & Associates 39 Clairedan Drive Powell, OH 43065

450 Alkyre Run Drive, Ste 230 Westerville, OH 43082 614.898.9340

614.436.4433/614.396.9310

PATIENT INFORMATION Preferred Name:

Patient Name:

Driver's License #:

SS#

Birthdate: Sex: Male ❑ Female

❑

Marital Status: ❑ Minor

❑ Single

Race: ❑ African American

❑Asian

❑ Married

❑ Long Term Partner

❑ Divorced

❑ Widowed [1] Separated

❑Caucasian ❑ Hispanic ❑Middle Eastern/Arabic ❑0ther: Work Phone:

Cell Phone:

Home Phone: Email Address: Home Address:

Employed:

Zip:

State:

City: ❑

Full Time

❑ Part Time

❑

Not Employed Occupation:

Employer: Employer Address: Student Status:

❑

Full Time

❑

Part Time ❑ Not Applicable School City/State:

School Name:

Relation:

Phone:

Emergency Contact Name: Who May We Thank for Referring You to Our Office:

FINANCIAL INFORMATION Relation to Patient:

Person Financially Responsible for Account: Birthdate:

Sex: Male ❑

Driver's License #:

SS#:

Female ❑

Home Address: Zip:

State:

City:

Work Phone:

Cell Phone:

Home Phone:

Email Address:

Employer Name:

*please note for children, the parent/guardian that brings the child to their appointment is responsible for payment on the account*

INSURANCE INFORMATION Primary Dental / Primary Medical Insurance

(please circle one)

Relation to Patient:

Insured Name: Birthdate:

Subscriber ID #:

SS#: Occupation:

Employer: Employer Address:

Group #:

Ins. Co. Phone #:

Insurance Company:

Secondary Dental / Secondary Medical Insurance

(please circle one)

Insured Name:

Relation to Patient:

Birthdate:

Subscriber ID #:

Subsriber SS#: Occupation:

Employer: Employer Address: Insurance Company:

Ins. Co. Phone #:

Group #:

By Signing Below, I verify the information provided is accurate to the best of my knowledge.

Patient Name

Name of Responsible Party

Signature of Responsible Party

Date

DENTAL HISTORY Dentist:

City, State:

Date of Last Visit:

Please check all that apply: ❑ Bad Breath ❑ Loose Teeth or Broken Fillings ❑ Bleeding Gums ❑ Current/Past Orthodontic Treatment ❑ Tooth Pain ❑ Dry Mouth ❑ Grinding Teeth ❑ Jaw/Joint Pain ❑ Food / Floss Catch Between Teeth

❑ Sensitivity to Sweets ❑ Joint Clicking / Popping ❑ Sensitivity to Hot/Cold ❑ Blisters on Lips/Mouth o Sensitivity to Biting ❑ Bumps / Growths in Mouth ❑ Swollen/Tender/Bleeding Gums ❑ Other:

MEDICAL HISTORY Date of Last Visit:

Primary Care Physician's Name: Referring Physician's Name:

Date of Last X-rays:

Phone Number:

Referring Physician's Phone Number:

Are you currently under the care of a physician? Y / N If yes, please describe: Other Physicians Currently Seeing: Please check all that apply: ❑ AIDS/HIV ❑ Depression ❑ Insomnia ❑ Abnormal Bleeding ❑ Diabetes Type 1/11 ❑ Kidney Disease ❑ Anemia ❑ Dizziness ❑ Liver Disease ❑ Anxiety ❑ Drug Addiction ❑ Low Blood Pressure ❑ Arthritis ❑ Emphysema/COPD ❑ Lung Mass ❑ Artificial Heart Valve(s) ❑ Epilepsy/Seizures ❑ Mitral Valve Prolapse o Artificial Joint(s) ❑ Fainting ❑ Osteoporosis ❑ Asthma ❑ Glaucoma ❑ Pacemaker o Back Problems ❑ Headaches ❑ Peripheral Vascular Disease o Bruises Easily ❑ Heart Attack / MI ❑ Peptic Ulcers o Cancer, Type/Diagnosis: ❑ Pregnantweeks ❑Chemical Dependency ❑ Heart Murmur ❑ Psychiatric Care ❑ Chemotherapy ❑ Heart Conditions ❑ Radiation Treatment o Chronic Fatigue Syndrome ❑ Hepatitis — Type__ ❑ Reflux / Hiatal Hernia ❑ CHF (Heart Failure) ❑ Herpes ❑ Sarcoidosis o Chronic Pain ❑ High Blood Pressure ❑ Seizures ❑ Other Medical Illnesses Not Listed: Drug/Medication Allergies: ❑ Allergy to Local Anesthetic ❑ Allergy to Latex Medicine Reaction Medicine

List any Prior Surgical History and Dates: Date

Surgery

❑ Sinus Trouble ❑ Skin Rash ❑ Sleep Apnea — Obstructive/Central ❑ Snoring ❑ Stomach Problems / Ulcers ❑ Stroke / TIA ❑ Swelling of Feet/Ankles ❑ Swollen Neck Glands ❑ Thyroid Problems/Disease ❑ Tobacco Use _Cigarettes /day _ Smokeless Tobacco _ Other ❑ Tuberculosis (TB) ❑ Venereal Disease ❑ Previous/Current Use of CPAP ❑ Previous Sleep Testing Reaction

List any other Hospital Admissions in the past: Date

Surgery

Please list any current medications including prescribed, over-the-counter (herbals, vitamins) you are presently taking: Medication Dosage Reason for Taking

Health Maintenance: Do you get a yearly Influenza vaccine? ❑ No o Yes Have you ever had a pneumococcal vaccine? ❑ No o Yes, Date: Have you ever had a tuberculosis skin test (PPD)? ❑ No ❑ Yes If Yes, Date: (o Positive ❑ Negative) I have reviewed the information provided on the form and have completed it to the best of my knowledge. I understand this information will be used by the Doctor and Staff to aid with the dental/medical treatment provided for myself/dependent. The information provided will be held in strict confidence in accordance with HIPAA Regulations. If there is a change in my health, it is my responsibility to notify the doctor/staff accordingly. I authorize Powell Dental Group to take digital x-rays, photographs, study models or any other diagnostic aids deemed appropriate to make a thorough diagnosis of my dental needs. I authorize payment directly from my insurance company to Powell Dental Group for all insurance benefits otherwise payable to me for services rendered. I authorize Powell Dental Group to release any and all information necessary to my insurance company, if required, strictly for the purpose of acquiring reimbursement for dental services. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents.

Patient Name

Name of Responsible Party

Signature of Responsible Party

Date

Review of Symptoms Past & Present DOB:

Patient Name: Weight:

Height:

Neck Circumference:

General ❑ Applies Denied Appetite Changes ❑ Applies ❑ Denied Marked Weight Change Denied Night Sweating ❑ Applies ❑ Applies ❑ Denied Recent Trauma/Infection ❑

❑

❑ Applies ❑ Denied Sensitivity to Heat/Cold ❑ Applies ❑ Denied Tires Easily Denied Unusual Weakness ❑ Applies ❑ Applies ❑ Denied Other: ❑

Head, Eyes, Ears, Nose and Throat ❑ Applies

Denied ❑ Applies ❑ Denied ❑

Dizziness

Headaches ❑ Applies ❑ Denied Nose Bleeding ❑ Applies ❑ Denied Ringing in Ears ❑ Applies Denied Sinus Infections Denied Sore Gums or Tongue ❑ Applies ❑

❑

❑ Applies ❑ Denied

❑ Applies ❑ Applies ❑ Applies ❑ Applies ❑ Applies

Sore Throat or Hoarseness

❑ Denied Swallowing Difficulties ❑ Denied Trauma ❑ Denied Ulcers or Lumps in Mouth Denied Other: ❑ Denied Other: ❑

Neck ❑ Applies ❑ Applies

❑

❑

Denied Neck Pain Denied Other:

❑ Applies ❑ Denied Neck Stiffness Denied Other: ❑ Applies ❑

Lungs ❑ Applies Denied Persistent Cough ❑ Applies Denied Shortness of Breath ❑ Applies ❑ Denied Other: ❑

❑

Denied Wheezing ❑ Applies ❑ Applies Denied Swelling of Ankles ❑ Applies ❑ Denied Other: ❑

❑

Heart ❑ Applies

❑

Denied High Blood Pressure

❑ Applies ❑ Denied Other:

Abdomen ❑ Applies ❑ Denied

Heart Burn

I ❑ Applies ❑ Denied Other:

Hematologic Denied Anemia ❑ Applies ❑ Applies ❑ Denied Bleeding Disorders ❑

Denied Bruises Easily ❑ Applies ❑ Applies ❑ Denied Other: ❑

Bone / Joints ❑ Applies Denied Back Pain ❑ Applies ❑ Denied Joint Stiffness ❑ Applies ❑ Denied Muscle Cramps ❑

❑ Applies ❑ Denied Myalgia ❑ Applies ❑ Denied Other: ❑ Applies Denied Other: ❑

Neurologic ❑ Applies ❑ Denied Cephalgia ❑ Applies ❑ Denied Dizziness ❑Applies ❑ Denied Headaches

❑ Applies ❑ Denied Muscle Weakness ❑ Applies ❑ Denied Muscle Paralysis ❑ Applies ❑ Denied ❑ Applies ❑ Denied

Reproductive ❑ Applies ❑ Denied

Impotence

❑ Applies ❑ Denied Lack of Sex Drive

Other ❑ Applies ❑ Denied Other:

I ❑ Applies ❑ Denied Other:

Watermark Medical ARES Questionnaire SCORING

PATIENT DEMOGRAPHICS

Neck Size +2 n6.5 (Male)

Middle Initial

First Name

Last Name

+2 15.0 (Female)

Date of Birth o Male

Height:

feet

inches

o Female

pounds

Weight:

inches

Neck Size:

+1 for each Yes Response

MEDICAL CONDITIONS: Have you been diagnosed or treated for any of the following conditions? High Blood Pressure

0 Yes

0 No

Stroke

0 Yes

0 No

Heart Disease

0 Yes

0 No

Depression

0 Yes

0 No

Diabetes

0 Yes

0 No

Sleep Apnea

0 Yes

0 No

Lung Disease

0 Yes

0 No

Nasal Oxygen Use

0 Yes

0 No

Do not assign any

Insomnia

0 Yes

0 No

Restless Leg Syndrome

0 Yes

0 No

Points for

Narcolepsy

0 Yes

0 No

Morning Headaches

0 Yes

0 No

Sleep Medication

0 Yes

0 No

Pain Medication

0 Yes

0 No

These eight responses

EPWORTH SLEEPINESS SCALE: How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to mark the most appropriate box for each situation. 0 = would never doze 1 1= slight chance of dozing 1 2 = moderate chance of dozing 1 3 = high chance of dozing Sitting and reading

0

1

2

3

Watching TV

0

1

2

3

Sitting, inactive, in a public place (theater, meeting, etc.)

0

1

2

3

As a passenger in a car for an hour without a break

0

1

2

3

Lying down to rest in the afternoon when circumstances permit

0

1

2

3

Sitting and talking to someone

0

1

2

3

Sitting quietly after lunch without alcohol

0

1

2

3

In a car, while stopped for a few minutes in traffic

0

1

2

3

Frequently 3-4 Times/wk

Always 5-7 Times/wk

Never

Rarely 0-1 times/wk

Sometimes 1-2 Times/wk

On average in the past month, how often have you snored or been told that you snore?

0 +0

0 +1

0 +2

0

+3

0 +4

Do you wake up choking or gasping?

0 +0

0 +1

0 +2

0

+3

0 +4

Have you ever been told that you stop breathing in your sleep/wake up choking or gasping?

0 +0

0 +1

0 +2

0 +3

0 +4

Do you have problems keeping your legs still at night or need to move them to feel comfortable?

0

+0

0 +0

0 +0

0 +0

0 +0

HABITS

By signing this agreement, you acknowledge that you have completed this form to the best of your knowledge. If your score is High Risk or above, is it recommended further testing be completed to evaluate/diagnose Sleep

Apnea or Sleep Disordered Breathing. If further testing is refused/denied, Powell Dental Group is not liable for undiagnosed medical conditions. Patient Signature: Date:

Epworth Score TOTAL the values from all 8 questions. If 11 or less, Score = 0 If 12 or more, Score = 2

Habits Score TOTAL the values For all answers

from the first 3 Habits questions

Total all 4 boxes above. Scoring chart 53 = No Risk 4 or 5 = Low Risk 6 to 10 = High Risk 211-- very High Risk

Affidavit For Intolerance To CPAP

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): Li Mask Leaks

•

An Inability to get the Mask to Fit Properly

O

Discomfort Caused by the Straps and Headgear

O

Disturbed or Interrupted Sleep Caused by the Presence of the Device

O

Noise From the Device Disturbing Sleep or Bed/Partner's Sleep

O

CPA? Restricted Movements During Sleep

•

CPAP Does Not Seem To Be Effective

•

Pressure On The Upper Lip Causes Tooth Related Problems

U

Latex Allergy

O

Claustrophobic Associations

•

An Unconscious Need to Remove the CPAP Apparatus at Night

U

Other

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

Powell Dental Group Comprehensive General, Restorative & Cosmetic Dentistry for Adults & Children Oral Systemic Health & Dental Sleep Medicine

Bed Partner Questionnaire Date: Name of Patient: Name of Person Filling Out Form:

Relationship:

I have observed this patient sleep: o Never o Once or Twice o o

Every Night Often

Please check all appropriate boxes of the following behaviors you have observed with this patient while they ar . _ Occasional Loud Light Snoring Loud Snoring o o o Snorts o Twitching or Kicking Choking Pauses in Breathing o o Legs During Sleep Sleepwalking Twitching or Jerking Grinding Teeth o o o of Arms During Sleep o o Crying Out Biting Tongue Getting out of Bed, o Not Awake Awakening with Head Rocking or o o Becoming very Rigid, o Pain Banging and/or Shaking o Apparently Other: Other: o o Sleeping even if Behaving Otherwise Please describe the sleep behaviors checked in more detail. Include a description of the activity, the time during the night when it occurs, frequency during the night, and whether it occurs every night. Please rank in severity. 1. 2. 3. 4. 5. Has the patient ever fallen asleep during normal daytime activities, or in dangerous situations? Yes: Please explain: No Is there any other pertinent information regarding the patient's sleep patterns that we should be aware of:

S le ep Solutions of Columbus dba Pulmonary & Sleep Consultants, L M. Qadoom, M.D. 450 Alkyre Run Drive, Ste 230 Westerville, OH 43082 614.898.9340

dba Powell Dental Group, LLC Shelley D. Shults, RN, DDS & Associates 39 Clairedan Drive Powell, OH 43065 614.436.4433/614.396.9310 Financial Policy

We welcome you to Sleep Solutions of Columbus, the offices of Dr. Shelley Shults & Dr. M. Qadoom. We look forward to providing you with the most exceptional dental/medical/sleep medicine care. To provide you with the most beneficial and comprehensive service and care, we do ask that you review and complete our office and financial policy consent form. We will gladly discuss your proposed treatment, financial options and any other questions you may have. We strive to keep you informed and involved with your treatment as much as possible. We feel that communication between the office/patient is essential to provide excellent care to avoid the least amount of confusion. 0 Payment for treatment is due at the time services are provided. Accepted forms of payment include cash, check, Mastercard,

Visa, Discover, and American Express. Financing options with credit approval is also available with CareCredit and Springstone Finance. If financing arrangements are required, this must be discussed with the billing office prior to the appointment whenever possible. 0 Any personal check returned unpaid or with non-sufficient funds (NSF) will incur a $50 NSF check fee in addition to the account balance. 0 Per the State of Ohio Law, if you have insurance, copayments and deductibles are due at the time of service. If a copayment needs to be billed, there will be a $15 processing fee. 0 If a minor is unaccompanied for their appointment and a copayment is due, arrangements must be made with the office prior to the appointment. o We accept any insurance that allows patients to see any provider of their choice. It is the patient's responsibility to verify if our offices are in network for their insurance carrier. 0 If your insurance requires a referral from your primary care physician, it is your responsibility to obtain the referral prior to your visit. o Patients with Medicare: Pulmonary and Sleep Consultants participates with and will bill directly to Medicare and your secondary insurance if secondary insurance information has been provided. If your secondary insurance does not respond in a timely manner, the patient will be responsible for any unpaid balance. Powell Dental Group does not participate with any medical insurance carrier. 0 As a complimentary service, our offices will file your claims for you. We do ask that the correct insurance information be provided so we can submit your claim accurately. If incorrect information is provided, you will be required to pay for your visit in full at the time of service. You can personally submit your claim to your insurance company for reimbursement. 0 We emphasize that as dental and medical care providers, our relationship is with you, not the insurance company. If difficulty arises with payment from the insurance company, we will ask that you contact your carrier directly to rectify the problem. All unpaid insurance balances older than 90 days from the date of service becomes the immediate responsibility of the patient/account holder. Please be aware that some services you may receive may not be covered by your insurance. Any estimate of insurance payment given by our office does not guarantee that your insurance company will reimburse us/you according to the estimate. Any unpaid balance not paid by the insurance company is the responsibility of the patient. 0 Balances older than 90 days will be subject to a monthly billing charge of $5.00 if payment is not received on the account. Any balance older than 90 days will be subject to interest charges of 1.5% per month until the account is paid in full. Any past due account balance older than 90 days risks being sent to a collection agency. Any additional collection fees will be applied to the past due account balance and are the responsibility of the patient. 0 In an effort to keep costs down while maintaining a high level of professional care, we respectfully request a 24 hour notice for cancellation of an appointment. If a 24 hour notice is not given for dental appointments, a $50 charge to your account may be applied. For Sleep Study Appointments, if a 48 hour notice is not given, a $250 cancellation fee will be applied. We appreciate your efforts to keep scheduled appointments and we will make every effort to continue to have convenient hours and prescheduled availability for you. o If you are 10 minutes late for your appointment, at the office manager's discretion, you may be asked to reschedule and may be charged a missed appointment fee. Our Purpose Statement is to provide services that exceed our patient's expectations with compassion, excellence and value, serving each other with care and respect, operating a practice that is strong, financially sound and state of the art, committed to never ending improvement. We pride ourselves in communication with our patients. If at any time you have any questions, please do not hesitate to ask.

By signing this form, I acknowledge that I have read and understand Sleep Solutions of Columbus' office policies. I have had the opportunity to have any questions answered to the best of Sleep Solutions of Columbus' ability.

Patient Name

Name of Responsible Party

Signature of Responsible Party

Date

1

Sleep Solutions of Columbus dba Powell Dental Group, LLC Shelley D. Shults, RN, DDS & Associates 39 Clairedan Drive, Powell, OH 43065 614.436.4433

dba Pulmonary & Sleep Consultants, LLC

M. Qadoom, MD 450 Alkyre Run Dr, Ste 230, Westerville, OH 43082 614.898.9340

Notice of Privacy Practices for Protected Health Information THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Updated Notice takes effect April 24, 2014 and will remain in effect until we replace it. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes in accordance with Section 164.520 of the code of Federal Regulations. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices or for additional copies of this Notice you may contact:

Powell Dental Group, LLC

Pulmonary & Sleep Consultants, LLC

Dr. Shelley D. Shults, RN, DDS 39 Clairedan Drive, Powell, Ohio 43065

M. Qadoom, M.D. 450 Alkyre Run Dr, Ste 230, Westerville, OH 43082 614.898.9640

614.436.4433

If you believe your privacy rights have been violated, you may make a complaint to one of the above addresses. The individual will not be retaliated against for making a complaint.

SECTION A: PERSON/PATIENT GIVING CONSENT Patient Name:

DOB:

Parent/Legal Guardian Name:

Relationship to Patient:

Address:

Telephone:

SECTION B: TO THE PATIENT — PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations. During the course of dental treatment, it may become necessary to disclose your protected health information to another entity, and agree to give consent to such disclosure for these permitted uses, including disclosures via email/fax. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description or our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or continue treating you if you revoke this Consent as permitted by Section 164.506 of the code of Federal Regulations.

SECTION C: USE AND DISCLOSURE OF HEALTH INFORMATION I,

, wish to ( Clallow

(You are not required to share/restrict information to anyone)

❑ restrict ) disclosure of my health information to:

(name), (relationship). I may revoke this disclosure with written notice to Sleep Solutions of Columbus and affiliates at any time.

SECTION D: RELEASE OF INFORMATION / SIGNATURE I request that payment of authorized health insurance benefits or Medicare benefits be made on my behalf to Sleep Solutions of Columbus, dba Powell Dental Group and/or Pulmonary and Sleep Consultants for any services provided to me. I authorize any holder of medical/dental information about me to release to CMS and its agents or my designated insurance carrier, any information needed to determine benefits/benefits payable for related services. I authorize Sleep Solutions of Columbus and related businesses/physicians/employees to release any necessary medical information about me to any third party or individual from whom payment for services may be rendered for purposes of obtaining a consultation, making a referral, continuity of my medical/dental care, quality assurance or peer review committee. I have had the full opportunity to read and consider the contents of this Consent form and Notice of Privacy Practices. I understand by signing this Consent form, I am giving my consent to the use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations. Patient/Legal Guardian Signature:

Date: If acting on behalf of a minor or if you are the legal guardian/Medical Power of Attorney, please inform Sleep Solutions of Columbus of: Patient's Name:

Your Relation to Patient:

Informed Consent for the Treatment of Obstructive Sleep Apnea Obstructive sleep apnea (OSA) is a medical condition that may be appropriate with a dental treatment called oral appliance therapy. For OSA to be treated by a dentist, a diagnosis of OSA must be made by a physician trained in the field of Sleep Medicine. If you have not been diagnosed with OSA by your physician, please understand that Dr. Shults will not proceed with treatment without an overnight sleep study in a sleep lab and a diagnosis of OSA by the attending physician. Dr. Shults will work in collaboration with your physician to achieve the best results possible for the treatment of your sleep apnea.

SUCCESFUL TREATMENT: Oral appliance therapy is a very effective treatment. However, no therapy works 100% of the time. The mandibular advancement device (MAD) works by moving the jaw and tongue forward at night which acts to keep the airway open. As with any medical therapy, successful treatment of OSA using dental appliances cannot be guaranteed. Success depends on many things. The most important component of success is patient compliance. By signing this document, you hereby agree to follow Dr. Shults' instructions in detail. Failure to do so may result in a poor clinical outcome. COMPLICATIONS OF TREATMENT: OSA is an unusual disease because it has been associated with many co-morbid medical conditions. As a result of OSA, or as a complication of OSA treatment, patients may develop any or all of the following: temporary or permanent co-morbid diseases, coronary artery disease, high blood pressure, diabetes, cerebrovascular disease, stroke, heart problems, heart attack, atrial fibrillation, depression, mood disorders, sexual dysfunction, weight gain, obesity, excessive daytime sleepiness, increased work related and traffic related accidents, and death. DENTAL ISSUES: A number of temporary or permanent dental issues can develop as a result of long term treatment of OSA with a mandibular advancement device (MAD) including but not limited to: jaw joint pain, moderate or severe TMJ dysfunction, headaches, backaches, neck aches, pain when chewing, facial pain, popping and noise in jaw, sore teeth, dental decay, gum (periodontal disease), gingivitis, worsening of periodontal pockets, tooth loss, loosening of teeth, dry mouth or excess saliva, fracturing or loosening of dental fillings/crowns/bridges, short term or long term bite changes, spacing or shifting of teeth, tilting of teeth, profile changes, lessening of overbite or overjet, dental infection, infection of the gums, difficulty chewing, oral cysts, oral tumors, oral cancer and death. You should be aware that complications as a result of oral appliance therapy have been minor. However, it is the patient's responsibility to immediately inform Dr. Shults of any issues which may develop to prevent a permanent condition or complication.

FINAL SLEEP STUDY AND EVALUATION: After your appliance is placed, it will be adjusted by Dr. Shults to achieve the best results possible. When your apnea symptoms have improved and Dr. Shults is satisfied with the results of the adjustments, you will be referred back to your physician for post-treatment evaluation and a post-treatment sleep study. This evaluation is to insure that your apnea is adequately controlled by the MAD and that no further adjustments or other treatment is needed. Your treatment must be confirmed by a study and evaluation by your physician after Dr. Shults completed the adjustments. Patient Initials

FOLLOW UP APPOINTMENTS: Appointments are required with Dr. Shults on a 6 month or yearly basis to check the effectiveness of your appliance and the success of your OSA treatment. Failure to maintain these follow up appointments will constitute a lack of compliance with Dr. Shults' treatment plan. Any decision on your part to forego follow up appointments places your health at risk and increases the probability of complications and treatment failure. Additionally, recall appointments should be kept with your general dentist on a three month schedule for the first year that you wear a MAD, to evaluate your dental hygiene, gums and check for decay. By signing this agreement you agree to schedule the recommended recall appointments and to use prescription oral topical fluoride daily for the prevention of decay and periodontal disease. The prescription fluoride is to be used for as long as you wear a MAD.

ALTERNATIVE TREATMENTS: By signing this consent form you acknowledge that you have been made aware of reasonable alternatives to MAD therapy for obstructive sleep apnea including, but not limited to: tracheotomy, CPAP, oral or pharyngeal surgery, positional sleep therapy, weight loss and exercise. Additionally, you are aware that more than one treatment may be necessary for the best results. WHEREFORE: I give my consent for the treatment of my OSA using a mandibular advancement device (MAD). I agree and consent to allow Dr. Shults and her staff to examine my mouth, teeth, jaws, gums and associated structures. I give consent for the taking of xrays, photos, impressions and any other procedures necessary for the treatment of my OSA. I also give consent for a home sleep calibration study if necessary, for the adjustment of my appliance. I consent for the contents of my records to be shared with my physician and insurance company. I affirm that I have read this document and have been given adequate information regarding treatment of my condition to give my informed consent. I understand the proposed treatment of my OSA using MAD therapy and I have been given the opportunity to ask questions. All of my questions have been answered and I am ready to proceed with treatment.

Patient Signature:

Date:

Please Print Patient Name: Witness: Printed Witness Name:

Date:

Dear Dr.

Records Release Authorization I hereby authorize and consent to: Powell Dental Group/Sleep Solutions of Columbus/Pulmonary and Sleep Consultants

To obtain copies of my medical and dental records from current or past dentists, physicians, psychologist, specialist, hospital, or any other medical/dental care provider. I authorize any health care provider who has treated me to discuss my care and treatment with: Powell Dental Group/Sleep Solutions of Columbus/Pulmonary and Sleep Consultants.

This authorization shall be valid until withdrawn by me, in writing. Please release any records, referrals, treatment notes, sleep study reports and prescription request for Sleep Apnea Oral Appliance (E0486) to: Powell Dental Group Shelley D. Shults, R.N., D.D.S. 39 Clairedan Drive Powell, OH 43065 (614)436-4433 Fax (614)436-6055 contactus(&,powelldentalgroup.corn

Patient/Parent/Guardian Signature

Patient(s) Printed Name:

Date

DOB