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.):
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/