Surgical Guide Order Form
for your surgical plan
Has the patient already scheduled an appointment?
Yes
No
Appointment Date
/
Month
/
Day
Year
Date Picker Icon
Restorative Doctor Information
Doctor Name
First Name
Last Name
Existing Customer
Yes
No
Organization Name
If different from your name
Office Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Invoice Restorative Doctor
Yes
No
Patient Information
Patient Name
First Name
Last Name
Are you planning tooth extraction?
Yes
No
Is there any bone grafting?
Yes
No
Surgeon Information
Surgeon Name
First Name
Last Name
Organization Name
Office Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Billing Email
example@example.com
Invoice Surgeon
Yes
No
Instructions
Surgical Guide Type
Maxilla
Yes
No
Partially edentulous
Full arch
Stackable guide
Area of Interest- tooth#
Mandible
Yes
No
Partially edentulous
Full arch
Stackable guide
Preferred Implant Brand
Company/Implant Name ex: Straumann/BLX
Pilot Drill Guide or Guide for a Guided Surgery System
Guide for Pilot Drill Only
Guide for a Guided Surgery System
Undecided
Drill Guide Sleeve Position
Gum Tissue Level
Bone Level
Depth Control
Undecided
Are you ordering Diagnostic Wax-Up?
Yes-Manual Diagnostic Wax-Up
Yes-Digital Diagnostic Wax-Up for planning purposes only
No
Teeth Numbers for Wax-Up
Prosthesis Shade:
Custom Sulcus former order
Please indicate if you want a custom sulcus former with your surgical guide for single tooth immediate implant.
3D printed sulcus former in pink color
Will send part
Order part
Sending files instructions:
For larger cases, we stronly recommend sending us a study model or ordering diagnostic wax-up. If you are ordering diagnostic wax-ups, please send us a dental cast, opposing model and bite registration.
Instructions for procedure.
Submitted Scan Data (check all that apply)
CBCT Scan of a patient (multi-file DICOM files)
CBCT Scan of an scan appliance (DUAL scan DICOM files)
Digital Dental Impression ( IOS) - STL file
STL send via SmileCloud
STL send via Dropbox
STL send via Itero
STL send via MEDIT
STL send via DEXIS
Digital dental scans (IOS) - STL file will be submitted by Surgeon
Digital dental scans (IOS) - STL file will be submitted by Restorative Dr.
Models for pick up and scanning
Intra oral scan and CT scans
Please upload any IOS( intra oral scans) in STL format Or CT scans in DICOM format on www.lhdentaldesignsolutions.com
Submit
Clear Form
Print Form
Should be Empty: