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About Us
Meet Dr. Jacobs
Technology
Insurance and FAQs
TMJ/Head & Facial Pain
Services
Sleep Apnea/Snoring
Botox
Cold Laser Therapy
TMJ Orthotics
Platelet-Rich Fibrin (PRF) Therapy
Prolotherapy
Snorelase
Patient Resources
About Us
Meet Dr. Jacobs
Technology
Insurance and FAQs
TMJ/Head & Facial Pain
Services
Sleep Apnea/Snoring
Botox
Cold Laser Therapy
TMJ Orthotics
Platelet-Rich Fibrin (PRF) Therapy
Prolotherapy
Snorelase
Patient Resources
BOOK an Appointment
Contact
Contact Us
Lunch & Learn
Contact
Contact Us
Lunch & Learn
Download our Insurance & FAQ forms
Insurance Form
FAQ Form
"
*
" indicates required fields
Have you been told that you Snore or know that you Snore/make breathing noises while sleeping?
*
Yes
No
Do you often feel Tired, fatigued or sleepy during the day?
*
Yes
No
Has anyone Observed you stop breathing during sleep?
*
Yes
No
Do you have or have you been treated for High Blood Pressure?
*
Yes
No
Is your Body Mass Index (BMI) more than 35 lbs/in²?
*
Yes
No
- Not Sure? Click here for
BMI Conversion Chart
Is your Age more than 50 years old?
*
Yes
No
Is your Neck circumference greater than 16 inches?
*
Yes
No
Is your Gender male?
*
Yes
No
PLEASE FILL OUT THE SHORT FORM BELOW AND WE WILL EMAIL YOU THE RESULTS.
Name
*
First
Last
Phone
Email