V2R Online Rx Form

Is this your first Smile in a Box case?*

YesNo

Customer name*

PrefixFirst NameLast Name

Customer e-mail*

Shiping address*

Street Address

References

City & CountyState / Province

Postal / Zip Code

Company name

Phone number

Mobile phone number (Optional)

Straumann customer number*

If you do not know it, you can write the full company name.

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 unitsFull arch / edentulous

Arch*

Waxup type for Maxilla*

Waxup type for Mandible*

Additional clinical observations

Implant system*

What surgical kit do you have?*

Kit Straumann® BL, BLT, TL (Steel T-Sleeve)Kit Straumann® BLX, TLX (Peek self-locking T-Sleeve)Kit Neodent® GM (NGS Drill Handle)Kit Neodent® EasyGuide (Narrow/Regular)Kit Neodent® EasyGuide (Regular/Wide)

Do you have experience in Guided surgery with this kit?*

YesNo

Numbering system

Implant sites (US)

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

Implant sites (FDI)

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

Implant sites (US)

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

Implant sites (FDI)

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

Click here for more information about the different guided surgery solutions

Additional instructions:

Planificación del tratamiento quirúrgico mediante coDiagnostiX™.
-Surgical treatment planning by coDiagnostiX™

Diseño de encerado digital mediante CARES® Visual
-Digital wax-up design by CARES® Visual

Diseño de la guía mediante coDiagnostiX™.
-Guide design by coDiagnostiX™

Impresión de la guía
-Guide print

Do you want to order an extra component?

Add a service (Single/Multi) for Straumann

Provisional to be design in a Variobase (Abutment sold separately)Provisional to be design in a Temporary Abutment (Abutment sold separately)

Add a service (Single/Multi) for Neodent

Provisional to be design in a Ti-Base/GM Exact (Abutment sold separately)Provisional to be design in a Temporary Abutment (Abutment sold separately)

Add a service (full arch)

Provisional for full arch FP1Provisional for full arch FP3

Shade*

Please indicate the patient's appointment date for the surgery (if known):

YearMonthDay

Upload your zipped 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.):

General Notes

Signature*

I declare that I have read, understood and accept the terms and conditions.

I understand and agree that I will be charged 50% in case I do not use the full service once the planning is done, according to the terms and conditions.

order.smileinabox.mex@straumann.com

example@example.com

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

Consult the indications of use

Consult terms and conditions

1. Patient information

2. Implant configuration

3. Remember, you order includes:

3. Extra service:

4. File upload and submission