Acknowledgement of the Risks of a Sleep Disorder
Date of Birth
Please read and check each box to applicable statements.
I am aware that I have a Sleep Disorder and the risks and consequences of this disorder.
I have been advised by the physician at the Tri-Hospital Sleep Laboratory West of the treatment of this disorder and the importance of using it regularly as prescribed.
I am fully aware that not complying with the treatment may result in an increased level of sleepiness, inattentiveness, reduced reaction times and increased accidents including motor vehicle and work related accidents.
I have also been made aware that untreated severe sleep apnea poses a sevenfold risk for motor vehicle accidents and a risk of harm to myself and the public.
I attest that I am not sleepy or inattentive while driving.
I have not fallen asleep while driving.
I have not had a near missed accident or an accident due to sleepiness, inattentiveness or falling asleep while driving.
This field is for validation purposes and should be left unchanged.