SIGUIDE - Order Form

SIGUIDE ORDER FORM

This form has a Save and Continue latest option. Save your progress and submit responses later.

If you wish to complete this guided case in two stages, kindly add your email in order to complete the form later.

View Surgical Scanning Guidelines Here!

If you require any further information or assistance with this form, please feel free to contact us siguide@southernimplants.com.au
View Pricing Guidelines Here!
Clinician Information:

IMPORTANT: If you do not have an account with SIA, we will use these details to create a cash account for you.
Southern Implants Account Number (if applicable)*
Type "NONE" if you do not have an account with SIA
Southern Implants Account Name*
Clinician Name*
Clinician Mobile Number*
Please enter a valid phone number.
Clinician Email*
example@example.com
Delivery Address (if different from recorded account address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Solutions Consultant (Sales Rep) Name*
Patient Information:
Patient Name (Reference)*

First NameLast Name
Date of Surgery *

DayMonthYear
not patient's birthdate
If Other, Please Specify
Is the Patient Insured?*
Surgery Details for Guide Planning:
Select Where the Surgical Guide is Required*
Select Guided System*

SP1 GuidedVersahSIREALTruGuidePilot GuideOther
Select Implant Type*

SP1Deep Conical (DC)External Hex (EX-HEX)Internal Hex (M-Series, PROVATA®)Internal Octagon (IT Connection)INVERTATRI-NEX®Other
Tooth Number/s*
Type of Surgery*

Immediate ExtractionFlap-less SurgeryRaised Flap SurgeryStackable GuideOther
Method of Shipping*

Digital DeliveryDigital and Postal Delivery
Please Place your Additional Order Here:

Please advise which components you would like to include in your package
Supply Implant(s)?*

YESNO
Include Cover Screw(s)?*

YESNO
Include Healing Abutment(s)?*

YESNO
Include Stabilizing Pins?*

YESNO
Include IrriGUIDE Adapter (ensures direct irrigation to the implant osteotomy site when using surgical guides)?*

YESNO
To learn more about IrriGUIDE, CLICK HERE
Provisional Restoration:

SIGuide can now supply a provisional restoration at a minor cost
Supply Provisional Restoration?*

YESNO
Provisional Tooth Number(s)*
or N/A
If YES, please advise "Shade"*
e.g. B1/2/3/4, A1/2/3/4, C1/2/3/4, D1/2/3/4, or N/A
Provisional Type*
Please share any further details that may be relevant?*
Terms & Conditions:

Disclaimer
In no event will Southern Implants Australia be liable to any party or for any direct, indirect, special, or other consequential damages, including without limitation, any lost profits, business interruption, or otherwise. Under no circumstances will Southern Implants Australia assume diagnosis, prognosis, or a course of treatment. Suitability of the product and/or service for the intended use will remain the risk and liability of the client. If the client does not supply dimensions, the technician will select the best possible length and diameter for approval by the clinician.

SIA will not be held responsible for any costs associated with the cancellation of the SIGuide or if it is no longer required. Any changes or cancellations of orders made after the submission of this form, will not be the responsibility of Southern Implants Australia.

SIA will not accept responsibility for any parcel deliveries. We recommend that parcels are sent with registered post/couriers to obtain proof of shipment.

IMPORTANT: Please revert back to this page to submit your surgical guide case. We won't receive your patient information if this Jotform has not been submitted.

To transfer files on WeTransfer please use siguide@southernimplants.com.au

Please use your Patient Name as references in the message box.

Shipping Instructions (shipping address has changed!):

If you were unable to upload the files or have a model instead of a scan, please print a copy of this form and send it along with the following items, raw Dicom data, models and any diagnostic wax-ups to

Attention: SI-GUIDE

Southern Implants Australia, WA Office

Unit 1/53 Winton Road, Joondalup WA 6027

T: +61 (0) 8 9466 2627

E: wa@southernimplants.com.au

Please allow 10-15 working days for planning and manufacturing.
Click HERE to upload STL

Click HERE to upload DICOM (Zip prior to sending)
Your case will be not be submitted without the STL and DICOM files.

Please hit the 'submit' button below in order to complete this surgical guide case.
Should be Empty:

Clinician Information:

Patient Information:

Surgery Details for Guide Planning:

Please Place your Additional Order Here:

Provisional Restoration:

Terms & Conditions: