This form serves as proof that a patient has received their custom-fit, adjustable oral appliance (CPT E0486). It confirms the appliance meets Medicare guidelines and that the patient has been instructed on its insertion, removal, activation, possible side effects, use of the AM Aligner, and home care. The patient acknowledges receiving personalized instructions, confirming the appliance fits comfortably, and expressing satisfaction with answers to their questions. It also includes a damage disclaimer outlining potential replacement fees for damage like pet damage or exposure to excessive heat.