Informed Consent for the TheraSnore (formerly Snore Guard) Appliance

The appliance which will be provided to you is designed widen your upper airway and significantly reduce/minimize, and perhaps for some, entirely eliminate the noise of snoring This device will not stop snoring for all individuals, and some patients will not be able to tolerate the device in their mouths. Because of this I cannot guarantee that this device will work for you. It has and still is working for me (10 years).

The TheraSnore appliance is similar to some orthodontic appliances which have been used for many years with an excellent record of safety. To the best of my knowledge no mishaps have ever been reported.

In addition to the above information, I understand and am aware of the following conditions which are applicable to the treatment with an appliance which opens the airway by forwardly repositioning the jaw when worn during sleep. (See http://www.sleepapneadentist.com/MRD.html for information about this general kind of appliance.):

1. Although the appliance is similar to an orthodontic appliance, it is not intended to permanently move my jaws or teeth.
2. The appliance will not "cure" my snoring. Its purpose is to prevent/minimize and possibly eliminate snoring from occurring while sleeping. It must be worn each night to produce the desired effect. When it is not worn my snoring will once again be present.
3. The possibility exists that problems could arise with my teeth, gums, jaws as a result of wearing the appliance.
4. I have chosen this method of treatment with full awareness that other treatment options are available to me including surgery and nasal continuous positive airway pressure (nNCPAP).
5. I understand that if I experience any dental, muscular, jaw joint (TMJ) discomfort as a result of wearing the appliance, I must stop wearing the appliance immediately and inform Dr. Rothstein.
6. I have been advised that I may experience temporary or permanent excess salivation.
7. I understand that since the appliance is molded (custom fitted) to my teeth the way they are now that any changes in them may result in an ill fit and consequently the appliance may need to be remade.
8. I have no known or preexisting jaw joint (TMJ) problems.

I acknowledge that I have read the above letter outlining the general treatment considerations for my therapy. I understand that there may be potential problems that not even Dr. Rothstein is aware of. I have had the opportunity to discuss treatment considerations and risks with Dr. Rothstein to clarify any areas I did not understand. Finally, I authorize Dr. Rothstein to make a snoring appliance for me. I have chosen the TheraSnore. http://www.distar.com.     I have chosen the Glidewell ("Silent Night") design. http://www.glidewell-lab.com/

Patient:_______________________ Date:_______________________________