V2R Online Rx Form

Is this your first Smile in a Box case?*

YesNo

Customer name*

PrefixFirst NameLast Name

Customer e-mail address*

Please enter the e-mail address associated to your Smile in a Box clinician account.

Company name

Shipping address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Phone number

Straumann customer number*

Click here if you are submitting files for an ongoing case

Smile in a Box™ case reference number*

The 8-digit number used for all Smile in a Box communications

Patient Identifier*

Case type*

SingleMultiple units

Condition and treatment scope

Arch*

Loading Approach

Temporary restoration

Additional clinical observations

Implant system

Implant surface

Surgical kit

Number of implants

Preferred alignment

Numbering system

Implant sites (US)

	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16

Implant sites (FDI)

	18	17	16	15	14	13	12	11	21	22	23	24	25	26	27	28

Implant sites (US)

	32	31	30	29	28	27	26	25	24	23	22	21	20	19	18	17

Implant sites (FDI)

	48	47	46	45	44	43	42	41	31	32	33	34	35	36	37	38

Preferred guided surgery solution

Sequential pin-supported solutionStackable solution

Click here for more information about the different guided surgery solutions

Additional instructions:

Would you like to order a temporary restoration?

YesNo

Coloring/Shades

Tooth shade*

Will you be providing a mock-up of the temporary?

YesNo

Please provide instructions and attach photos of the patient in section 6 (if available)

Should you want to expand on the information provided above and discuss prosthetics in more detail, please contact us (1-514-587-8359) or your partner lab.

Ordered services

Full Service

Please select from the following services:

Surgical treatment planning by coDiagnostiX™Digital wax-up design by CARES® VisualSurgical guide design by coDiagnostiX™Temporary restoration design by CARES® VisualCentralized manufacturing of the surgical guidesCentralized manufacturing of the temporary restorationComponent order (implants, abutments and auxiliaries)

Additional ordered services

3D printed master model

Preferred treatment plan review method*

Interactive: Smile in a Box will contact you to schedule an online meeting to review and adjust the plan prior to submitting the report (mandatory for full arch restoration)Document-based: Smile in a Box will submit a report for you to review and approve

Preferred treatment plan review method*

Interactive: Smile in a Box will contact you to schedule an online meeting to review and adjust the plan prior to submitting the report (mandatory for full arch restoration)

Important note on surgery scheduling:

According to our average turnaround times and the above chosen services, please expect a minimum of 3 weeks (15 business days) for a single-unit/multiple-unit case.

Planned surgery date (if known, see above):

YearMonthDay

The planned surgery date you entered leaves insufficient time to process your case. We highly recommend to schedule the surgery once the treatment plan has been approved.

The chosen services cannot be delivered at the chosen date. Please select a new date.

Upload your files here (patient pictures, CT scans in DICOM format and models in .stl format):

Browse Files

Please upload all files in .zip format.

If your files cannot be uploaded, please provide a link to a cloud storage (dropbox, box, drive, hightail, etc.):

3Shape Communicate® Order ID (if applicable)

xxxxxxxxxx_xxxxxxxx_xxxx_xx

General Notes

Signature*

Firma*

Please wait for the confirmation prior to navigating away from this page. Upon successful submission, you will also receive an e-mail confirmation.

1. Patient information

2. Implant configuration

3. Prosthetic design

4. What would you like to include with your order?

5. Treatment Scheduling

6. File upload and submission